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OPERATIVE   GYNECOLOGY 


VOLUME   II 


OPERATIVE   GYNECOLOGY 


BY 


HOWARD  A.   KELLY,    A.  B.,    M.  D. 


FELLOW   OF  THE   AMERICAN    GVNECOLOGIC;» L   SOCIETY; 

PROFESSOR   OF   GYNECOLOGY   AND    OBSTETRICS   IN   THE   JOHNS   HOPKINS   UNIVERSITY, 

AND   GYNECOLOGIST  AND    OBSTETRICIAN    TO   THE    JOHNS    HOPKINS    HOSPITAL,    BALTIMORE  ; 

FORMERLY    ASSOCIATE    PROFESSOR    OF    OBSTETRICS    IN    THE    UNIVERSITY    OF    PENNSYLVANIA  ; 

CORRESPONDING   MEMBER   OF   THE   SOClfiT^   OBST^TRICALE   ET   GYNficOLOGIQUE   DE    PARIS, 

AND    OF   THE   GESELLSCHAFT   FUR   GEBURTSHOLFE   ZU   LEIPZIG 


WITH    TWENTY-FOUR  PLATES  AND 
FIVE  HUNDRED  AND  NINETY  ORIGINAL  ILLUSTRATIONS 


VOL.     II 


NEW    YORK 

D.    APPLETON    AND    COMPANY 

1898 


Copyright,  1898, 
By  D.  APPLETON  AND  COMPANY. 


COiS^TEl^TS 


CHAPTER  PAGE 

XX.    General  principles  and  complicatioxs  common  to  abdominal  operations    .  1 

XXI.     Care  of  wound  and  patient  tp  to  recovery 44 

XXII.    Complications  arising  after  abdominal  operations 06 

XXIII.    Tubercular  peritonitis I34 

XXI 7.    Suspension  of  the  uterus I49 

XXV.     Conservative  operations  on  the  tubes  and  ovaries 163 

XXVI.     Simple    salpingo-ouphorectomy   and   salpingo-oophorectomy   for    adherent 

TUBES    AND    OVARIES 193 

XXVII.    Vaginal  drainage  and  enucleation  for  pyosalpinx,  ovarian  abscess,  tubo- 

OVARIAN   ABSCESS,    AND    PELVIC    ABSCESS 209 

XXVIII.     Hysterectomy,  with  extirpation  of  ovaries  and  tubes — abdominal  hystero- 

SALPiNGO  oophorectomy 236 

XXIX.     Ovariotomy 246 

XXX.     Abdominal  hysterectomy  for  carcinoma  and  sarcoma  of  the  uterus  .        .  305 

XXXI.     Myomectomy — hystero-myomectomy 338 

XXXII.     Operations  during  pregnancy 403 

XXXIII.  Cesarean  section 415 

XXXIV.  Extra-uterine  pregnancy 428 

XXXV.    The  radical  cure  of  hernia 467 

XXXVI.     Intestinal  complications 492 

XXXVII.     The  more  remote  results  of  abdominal  operations 518 

XXXVIII.    Ox  THE  conduct  of  autopsies,  the  making  of  protocols,  and  the  preserva- 
tion of  tissues  for  microscopic  examination  in  gynecological  practice  .  531 

V 


LIST    OF   ILLUSTRATIONS. 


FTG.                                                                                                                "  PARE 

316.  Stricture  of  rectum  due  to  pelvic  inflammatory  disease 20 

317.  Vermiform  appendix  adherent  to  a  large  papillary  ovarian  cyst 21 

318.  Extensive  pelvic  inflammatory  disease  with  general  adhesions 22 

319.  The  clear  space 24 

320.  Encysted  silk  ligature  in  the  right  broad  ligament 25 

321.  Closure  of  the  abdominal  wound 42 

322.  323,  324,  325.  Showing  the  average  charts,  or  composite  temperatures  and  pulse  rates 

in  ten  cases  in  each  group 54 

326.  Introducing  normal  salt  solution  under  the  breasts  in  case  of  extreme  anemia          .         .  70 

327.  Chart  showing  convalescence  complicated  by  a  high  pulse  rate 72 

328.  Normal  convalescence  interrupted  by  periodical  rises  of  temperature  due  to  the  presence 

of  the  Plasmodium  malaria? 75 

329.  Chart  of  a  case  of  septic  peritonitis  following  myomectomy 86 

330.  Chart  of  a  case  of  general  sepsis  following  a  perineal  operation 102 

331.  Chart  of  a  case  of  septicemia  from  a  purulent  peritonitis 103 

332.  Chart  showing  an  abdominal  operation  complicated  by  pneumonia 108 

333.  Stitch-hole  abscess  chart 115 

334.  Tubercular  left  tube  with  adherent  omentum 135 

335.  Tubercular  right  tube,  with  tubercles  over  a  parovarian  cyst 135 

336.  General  tubercular  peritonitis 136 

337.  Tuberculosis  of  tubes  and  ovaries 144 

338.  Tuberculosis  of  the  tube 144 

339.  Diagram  showing  the  relative  advantages  of  closing  or  of  draining  the  abdomen  in 

tubercular  peritonitis 146 

340.  Composite  chart,  showing  course  of  fever  after  operation  in  tulicrcular  peritonitis,  with- 

out drainage 14G 

341.  Chart  showing  recovery  after  removal  of  tubes  and  ovaries  in  tubercular  peritonitis         .  147 

342.  Suspension  of  the  uterus,  seen  from  above ■      ,  150 

343.  Steps  in  the  reduction  of  the  uterus  in  the  palliative  treatment  of  retroflexion ;  anterior 

lip  of  cervix  grasped  with  tenaculum  forceps 151 

344.  Same,  traction  straightening  out  the  angle  of  flexion 151 

345.  Same,  the  finger  in  rectum  induces  slight  anteflexion 152 

346.  Same,  forceps  carrying  the  cervix  back  into  the  pelvis 152 

347.  Same,  the  retroflexion  reduced 153 

348.  Production  of  an  extreme  anteposition 154 

349.  Suspension  of  the  uterus  within  a  year  after  the  operation 155 

350.  Suspension  of  the  uterus,  seen  a  year  after  the  original  oi)eration 156 

351.  Upper  elevator 159 

352.  Lower  elevator 159 

353.  Suspension  of  the  uterus,  showing  elevation  of  the  uterus  with  the  lower  elevator  .         .  160 

354.  Suspension  of  the  uterus 160 

355.  Suspension  of  the  uterus,  as  seen  from  above 161 

356.  Suspension  of  the  uterus ;  outline  of  ojyeration  completed 161 

vii 


Vlll  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

357.  Conservative  operation  on  the  ovary 174 

358.  Parovarian  cyst  removed  from  left  broad  ligament 175 

359.  Parovarian  cyst  extirpated  without  removing  either  tube  or  ovary 176 

360.  Hypertrophy  of  the  ovary,  with  cystic  degeneration 178 

361.  Hemorrhagic  corpus  luteum  cyst  and  cystic  Graafian  follicle  in  same  ovary     .         .         .  179 

362.  Cyst  of  the  corpus  luteum 180 

363.  Pedunculate  corpus  luteum  cyst  of  the  left  ovary 181 

364.  Cysts  of  corpora  lutea  in  both  ovaries 181 

365.  Vclamentous  adhesion  of  the  right  uterine  tube  to  itself  and  to  the  uterine  cornu   .        .  183 

366.  Angular  attachment  of  the  left  uterine  tube  to  the  cornu  of  the  uterus    ....  184 

367.  Adhesions  of  the  outer  free  extremities  of  both  uterine  tubes  to  the  ovaries     .        .        .  185 

368.  Conservative  operation  to  preserve  the  right  ovary  and  left  tube 188 

369.  Diagram  of  same  after  removal  of  the  right  tube  and  left  ovary 189 

370.  Double  hydrosalpinx 200 

371.  Large  left  hydrosalpinx,  with  numerous  adhesions 201 

372.  Double  hydrosalpinx,  with  adhesions 201 

373.  Hydrosalpinx 202 

374.  Hydrosalpinx,  with  few  convolutions 202 

375.  Same,  in  longitudinal  section 202 

376.  Hydrosalpinx  containing  a  nodular  S-shaped  calculus 203 

377.  Hydrosalpinx,  with  congenital  deficiency  in  the  tube 203 

378.  Right  tubo-ovarian  cyst 204 

379.  Same,  laid  open 205 

380.  Tubo-ovarian  cyst,  from  right  side 205 

381.  Same,  divided 205 

382.  Outline  of  the  torsion  of  the  pyosalpinx  shown  in  the  colored  plate 209 

383.  Large  abscess  of  the  right  ovary 214 

384.  Abscess  of  the  ovary,  laid  open 215 

385.  Nodular  salpingitis 215 

386.  Opening  a  retro-uterine  pelvic  abscess  by  puncture 224 

387.  Stout  curved,  saw-toothed  traction  forceps 225 

388.  Conservative  treatment  of  abscess  of  both  Fallopian  tubes 228 

389.  Same,  showing  gauze  drain  behind  uterus  and  extending  down  into  vagina     .        .        .  229 

390.  Ovarian  abscess 234 

391.  Double  pyosalpinx,  with  carcinoma  of  the  cervix 235 

392.  Extirpation  of  myomatous  uterus,  ovaries,  and  tubes,  with  a  left  ovarian  cystoma  .         .  237 

393.  Hystero-salpingo-oophorectomy  for  large  double  hydrosalpinx 240 

394.  Outline  showing  extirpation  of  the  uterus,  tubes,  and  ovaries  by  a  continuous  incision    .  241 

395.  Extirpation  of  uterus,  tubes,  and  ovaries  for  pelvic  peritonitis 243 

396.  Diagram  showing  the  relations  of  an  ovarian  cyst  to  the  peritoneum  of  the  pelvic  floor 

and  broad  ligament 248 

397.  Long  pedicle  of  a  papillary  ovarian  adeno-cystoma 249 

398.  Diagram  showing  the  relations  of  an  intraligamentary  cyst  to  the  anterior  and  posterior 

layers  of  the  peritoneum  of  the  broad  ligament 250 

399.  Adherent  cyst  of  the  ovary  showing  the  mimicry  of  the  intraligamentary  cyst        .         .  250 

400.  Parasitic  ovarian  cyst  of  left  side,  with  general  peritoneal  carcinosis        ....  250 

401.  Left  ovarian  cyst  with  a  twisted  pedicle 251 

402.  Same,  pedicle  untwisted  to  show  its  anatomical  elements 251 

403.  The  relations  of  the  parasitic  multilocular  ovarian  cyst  shown  in  inset  Fig.  400      .        .  251 

404.  Ovarian  cyst  showing  natural  perforation,  with  discharge 252 

405.  Large  multilocular  ovarian  cyst  in  a  negress 253 

406.  Typical  polycystic  ovarian  tumor,  with  long  twisted  pedicle 259 

407.  Multilocular  ovarian  cyst,  in  which  smaller  cysts  project  into  the  cavity  of  the  large  one  .  260 

408.  Polycystic  ovarian  tumor  and  parovarian  cyst  existing  on  the  same  side  .        .         .         .261 

409.  Multiple  adeno-cystomata  of  the  ovary 262 


LIST    OF    ILLUSTRATIOXS. 


IX 


with 


of 


FIG. 

410.  "^'all  of  a  raultilocular  ovarian  cyst  magnified  170  times    . 

411.  Papillomata  of  both  ovaries,  seen  in  situ  from  behind 

412.  Inner  surface  of  a  papillo-adeno-cystoma  of  the  left  ovary 

413.  Cysto-papilloma  of  the  ovary 

414.  Solid  or  fibroid  papillary  adenoma  of  the  ovary 

415.  Adeno-carcinoma  (colloid  carcinoma)  of  the  ovary 

416.  Cysto-carcinoma  of  the  ovary  of  unusual  form  .... 

417.  Flat  carcinomatous  metastatic  nodules  on  the  intestines    . 

418.  Large  adeno-carcinoma  (colloid  carcinoma)  of  the  omentum 

419.  Adeno-carcinoma  of  the  omentum,  seen  in  section 

420.  Rudimentary  jaw  from  a  dermoid  cyst  containing  molar  teeth,  and 

growing  from  its  extremity 

421.  Contour  of  the  abdomen  in  the  case  of  an  unusually  large  dermoid  cyst 

422.  Left  dermoid  cyst  of  the  ovary  with  a  long  pedicle    . 

423.  Complicated  dermoid  cyst  of  the  right  ovary      .... 

424.  Right  dermoid  cyst  with  extensive  adhesions      .... 

425.  Parovarian  cyst  situated  between  the  ampulla  of  the  tube  and  the  outer  end  of  the  c 

426.  Parovarian  cyst,  showing  its  translucency  and  the  uterine  tube  spread  out  on  its  sur 

427.  Parovarian  cyst,  with  subsidiary  cysts  lying  beneath  the  tubo-ovarian  fimbria 

428.  Parovarian  cyst  bulging  out  on  both  sides  of  the  tube 

429.  Cyst  of  the  parovarium 

430.  Parovarian  cyst 

431.  Parovarian  cyst  with  twisted  pedicle 

432.  Subperitoneal  cyst  developed  entirely  from  the  peritoneum 

433.  The  pedicle  of  the  hydatid  tied  about  the  free  tubal  fimbria  at  its  base 

434.  Same,  enlarged,  showing  appearance  of  the  degenerated  fimbria 

435.  Fibroid  tumor  of  the  ovary 

436.  Calculus  of  the  ovary 

437.  Partially  calcified  fibroma  of  the  right  ovary 

438.  Angio-sarcoma  of  the  left  ovary,  with  metastasis  in  the  uterus 

439.  Monocystic  tumor  of  the  left  broad  ligament 

440.  Suppurating  adherent  ovarian  cyst 

441.  Suppurating  adherent  ovarian  cyst 

442.  Same,  cross-section  of  the  intestinal  and  mesenteric  attachment 

443.  Diagram  from  a  case  of  intraligamentary  cyst,  seen  from  above 

444.  Same,  showing  closure  of  wound  after  enucleation  of  cyst 

445.  Tntraliganientary  Graafian  follicle  cysts,  in  situ  .... 

446.  Same,  removed 

447.  Multiple  dermoid  cysts  of  botli  ovaries 

448.  Ijeft  dermoid  cyst  and  right  multilocular  ovarian  cyst  with  twisted  pedi 

449.  Fibroma  of  the  left  ovary  with  large  myomata  of  the  uterus    . 

450.  Adeno-carcinoma  of  the  cervix,  with  hydroureter  of  both  sides 

451.  Carcinoma  of  the  cervix 

452.  Extensive  epithelioma  of  the  cervix 

453.  Inoperable  epithelionui  of  the  cervix 

454.  Adeno-carcinomatous  nodule  entirely  concealed  within  the  cervix    . 

455.  Adeno-carcinoma  of  the  body  of  the  uterus,  growth  stopped  at  internal  os 

456.  Adeno-carcinoma  of  the  body  of  the  uterus         .... 

457.  Same,  cut  through  the  anterior  wall 

458.  Adeno-carcinoma  of  the  uterine  body,  with  metastatic  nodules  in  the  lyni 

the  left  broad  ligament 

459.  Limited  area  of  carcinoma  of  the  fundus  of  tlie  uterus  on  the  left  sidt 

460.  Operation  for  carcinoma  of  the  uterus 

461.  Carcinoma  uteri 

462.  Double  hvdroureter  due  to  advanced  cancer  of  the  cervix  uteri 


ai-y 
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hair 


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hannels  of 


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X  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

463.  Autopsy  on  a  case  of  carcinoma  of  the  cerrix ;  hydroureter,  with  double  ureter  on  the 

left 319 

464.  The  upper  half  of  a  hydi-oureter,  with  hydronephrosis  from  compression  due  to  a  can- 

cerous cervix 320 

465.  Relations  of  the  ureter  and  bladder  to  the  uterus  and  vagina 323 

466.  Diagram  showing  stoppage  of  bougie  in  the  ureter  in  the  operation  for  carcinoma  of  the 

cervix 324 

467.  Outline  diagram  of  the  steps  of  the  radical  operation  for  cancer  of  the  cervix  .         .  325 

468.  Hysterectomy  for  carcinoma  of  the  cervix  ;  left  broad  ligament  opened  up      .         .         .  326 

469.  Same,  the  left  uterine  artery  tied  and  cut  off 327 

470.  Same,  bladder  freed  and  vaginal  vault  opened  anteriorly 329 

471.  Same,  in  sagittal  section,  showing  the  left  side  of  the  pelvis,  with  the  operation  completed.  330 

472.  Epithelioma  of  the  cervix  in  grapelike  mass 331 

473.  Uterus  enucleated  per  vaginam,  in  contrast  with  this  method 332 

474.  Small  sarcoma  in  the  right  horn  of  the  uterus 333 

475.  Sarcoma  of  the  body  of  the  uterus 333 

476.  Sarcomatous  nodule  in  the  vagina 334 

477.  Sarcoma  of  the  uterus  and  right  ovary 335 

478.  Same,  uterus  cut  open  in  front 336 

479.  Greatly  enlarged  right  ovary  removed  with  a  myomatous  uterus 340 

480.  Uterus  with  extensive  myomatous  involvement 342 

481.  Myomatous  uterus,  showing  interstitial  and  subperitoneal  masses 343 

483.  Diagram  of  Case  J.  S.  S.,  San.  107 344 

483.  Globular  myomatous  uterus  presenting  form  of  pregnant  uterus  at  term ....  345 

484.  Myomatous  uterus,  exhibiting  a  perfect  cast  of  the  pelvis 346 

485.  Large  subperitoneal  myoma,  seen  from  behind 347 

486.  Pedunculated  myomata,  giving  a  perfect  ballottement 350 

487.  Large  globular  myoma  choking  the  pelvis 353 

488.  Same,  lifted  up  into  the  abdomen 353 

489.  Uterus  after  extirpation  of  a  myomatous  tumor,  showing  great  muscular  hypertrophy    .  356 

490.  Myomatous  uterus,  conservative  operation 358 

491.  Conservative  treatment  of  the  myomatous  uterus 358 

492.  Same,  after  removal  of  the  tumors 359 

493.  Cullen's  myoma  enucleator 359 

494.  Myomatous  uterus  from  which  eight  myoma  wei'e  enucleated  by  seven  incisions      .         .  361 

495.  Same,  showing  incisions  closed  by  interrupted  catgut  sutures 361 

496.  Large  submucous  myoma 363 

497.  Schematic  diagram,  showing  incision  from  left  to  right  in  extirjiating  the  myomatous 

uterus 369 

498.  The  operation  of  hystero-myomectomy 371 

499.  The  last  step  in  the  enucleation  of  the  myomatous  uterus 372 

500.  Complicated  hystero-myomectomy  (hydrosalpinx  and  ovarian  cyst) 375 

501.  Complicated  hystero-myomectomy  (intestinal  and  omental  adhesions)       ....  376 

502.  Globular  myomatous  uterus  complicated  by  dei-moid  cysts  of  the  left  ovary     .         .         .  379 

503.  Myoma  and  carcinoma  in  a  negress 380 

504.  Myoma  with  cystic  degeneration 381 

505.  Large  fibro-cystic  tumor  of  the  uterus  attached  to  a  multinodular  myomatous  uterus     ,  382 

506.  Torsion  of  the  globular  myomatous  uterus  from  left  to  riglit 383 

507.  Same,  untwisted 384 

508.  Pelvis  choked  by  a  cup-and-ball  myoitia 391 

509.  Large  myomatous  uterus  filling  the  lower  two  tliirds  of  the  abdomen       ....  391 

510.  Displacement  of  the  bladder  due  to  a  large  myomatous  uterus 391 

511.  Large  cystic  myoma  of  the  left  broad  ligament  filled  with  pus 394 

512.  Myomatous  uterus  weighing  thirty-nine  pounds 396 

513.  Complicated  hystero-myomectomy,  showing  extensive  subperitoneal  (leveloi)ment  .         .  397 


LIST    OF    ILLUSTRATIONS.  XI 


FIG.  Pf«^ 

514.  Complicated  hystero-myoraectomy 399 

515.  Myomatous  uterus  presenting  an  extraordinary  mimicry  of  a  child  in  a  transverse  po- 

sition           401 

516.  Cesarean  uterus  removed  six  years  after  operation 420 

517.  Porro-Cesarean  section  for  fibroid  uterus  at  term 425 

518.  Extra-ulerine  pregnancy  gone  some  six  or  eight  months  beyond  term      ....  428 

519.  Tubal  diverticula  forming  the  two  rounded  eminences  on  the  upper  border  of  the  am- 

pulla           431 

520.  Triple  tubal  ostia 433 

521.  Fetus  and  umbilical  cord  found  lying  among  clots  in  abdominal  cavity  ....  438 

522.  Extra-uterine  pregnancy 439 

523.  Ruptured  left  extra-uterine  pregnancy  with  large,  free  intraperitoneal  hemorrhage        .  439 

524.  Extra-uterine  pregnancy,  showing  tube  east 440 

525.  Extra-uterine  tubal  mole  filling  and  distending  the  ampulla 441 

526.  Extra-uterine  pregnancy  :  cross  section  of  the  tubal  wall  in  the  ampulla.         .         .        .  445 

527.  Extra-uterine  pregnancy  ;  tubal  abortion 450 

528.  Same,  coagulura  turned  out 450 

529.  Extra-uterine  pregnancy  (right),  w'ith  tubal  abortion 453 

530.  Operation  for  ruptured  extra-uterine  pregnancy 452 

531.  Lithopedion  lying  undisturbed  in  the  abdominal  cavity 460 

532.  Lithopedion  removed  from  the  abdominal  cavity  four  years  after  a  false  labor        .        .  461 

533.  Pregnancy  in  a  rudimentary  left  uterine  horn  ;  rujature,  death 465 

534.  Hernia  of  the  pregnant  uterus  in  the  negress 467 

535.  General  principles  of  the  radical  operation  for  hernia ;  incision  made  and  hernial  sac 

protruding 4G9 

536.  Same,  with  the  sac  returned  and  sutures  laid 470 

537.  Same,  with  the  silver-wire  mattress  sutures  drawn  up,  twisted,  and  the  ends  turned  down  .  470 

538.  Same,  the  mattress  suture  tied 471 

539.  Same,  interrupted  catgut  sutures  passed,  but  not  yet  tied,  in  the  intervals  between  the 

mattress  sutures 471 

540.  Operation  for  a  ventral  hernia 472 

541.  Tissues  grasped  by  the  mattress  sutures  in  closing  the  hernia 473 

542.  Mattress  sutures  uniting  the  recti  muscles  and  their  overlying  fasciai       ....  473 

543.  Incarcerated  umbilical  hernia  in  a  fat  woman 474 

544.  Same,  the  hernial  sac  removed 475 

545.  Anatomy  of  the  inguinal  canal 476 

546.  Anatomy  of  the  inguinal  canal  in  its  deeper  layers 477 

547.  First  step  in  the  operation  for  inguinal  hernia ;  the  sac  exposed 478 

548.  Second  step  of  same ;  the  sac  drawn  out  of  wound 479 

549.  Third  step  of  same ;  the  sac  incised 480 

550.  Fourth  step  of  same ;  closure  of  neck  of  sac  with  mattress  sutures 481 

551.  Fifth  step  of  same ;  closure  of  the  inguinal  canal  with  silver-wire  mattress  sutures         .  482 

552.  Sixth  step  of  same;  the  mattress  sutures  drawn  up  and  twisted,  and  the  wound  being 

closed  by  a  continuous  suture 483 

553.  Operation  for  the  radical  cure  of  a  large  inguinal  hernia  where  the  conjoined  tendon  is 

deficient 484 

554.  Showing  the  facility  with  which  the  rectus  muscle,  released  from  its  sheath,  can  be  drawn 

over  and  attached  to  Poupart's  ligament,  covering  in  the  entire  inguinal  canal  .        .  485 

555.  Partial  hernia  of  the  left  ovary 488 

556.  Left  femoral  hernia 490 

557.  ]\Iethod  of  dealing  with  intestinal  adhesions  where  an  interval  can  be  developed  be- 

tween the  bowel  and  the  adherent  surface  by  slight  traction 492 

558.  First  step  in  the  operation  for  appendicitis 498 

559.  Second  step  in  the  operation  for  appendicitis 499 

560.  Third  step  in  the  operation  for  ai)pcndiciti3 500 


Xll  LIST   OF    ILLUSTEATIONS. 

Fie.  PAGE 

561.  Retracted  appendical  stump  within  a  cuff  of  peritoneum 501 

562.  Closure  of  the  peritoneal  cuff  over  the  stump  by  mattress  and  interrupted  sutures .         .  502 

563.  Inversion  and  extraperitoneal  disposal  of  the  little  buttonlike  stump  beneath  the  con- 

tiguous margins  of  the  mesenteriolum 502 

564.  Curved  intestinal  needle 503 

565.  Halsted's  method  of  preserving  the  intestinal  needles 503 

566.  Human  small  intestine  magnified  one  hundred  times  to  show  the  relative  thickness  of 

the  various  coats 504 

567.  A  section  of  the  colon  magnified  one  hundred  times 504 

568.  Cross-section  of  the  rectum  magnified  twenty-five  times 505 

569.  Lateral  anastomosis.     First  step  ;  ends  of  bowel  closed  and  mattress  sutures  introduced 

on  the  lower  side 506 

570.  Same,  second  step  ;  lower  row  of  sutures  tied  and  the  lateral  sutures  applied  .        .        .  506 

571.  Same,  third  step  ;  lateral  sutures  tied,  making  a  pocket 507 

572.  Same,  fourth  step  ;  remaining  sutures  in  place  ready  to  complete  the  union  on  all  sides  507 

573.  Same,  completed ;  all  sutures  tied 508 

574.  End  to  end  anastomosis  without  artificial  aids  ;  presection  sutures  in  place     .        .        .  508 

575.  Same  ;  presection  sutures  tied 509 

576.  Same  ;  mattress  sutures  in  place 509 

577.  Same  ;  sutures  all  tied,  accurate  approximation  of  divided  ends  of  bowel        .        .        .  509 

578.  Circular  suture  of  the  intestine 510 

579.  One  of  the  divided  ends  of  the  intestine 511 

580.  The  introduction  of  the  collapsed  rubber  cylinder  between  the  presection  sutures  .        .511 

581.  After  tying  the  three  presection  sutures  and  inserting  the  rubber  bag  a  fourth  stitch,  b, 

is  inserted 511 

582.  The  mesenteric  mattress  suture  devised  by  Mitchell  and  Hunner 511 

583.  From  ten  to  twelve  mattress  sutures  are  introduced,  and  the  tying  begun  with  the 

mesenteric  suture  a 512 

584.  Two  sutures  separated  to  allow  the  deflated  bag  to  be  withdrawn 513 

585.  Sutures  all  tied,  and  the  anastomosis  completed 514 

586.  Anastomosis  of  the  sigmoid  into  the  ampulla  of  the  rectum 515 

587.  Making  a  sigmoid  anus  in  occlusion  of  the  lower  bowel 516 

588.  Making  a  sigmoid  anus 517 

589.  Post-operative  intra-abdominal  hernia 518 

590.  Strangulated  hernia  in  a  patient  seventy-five  years  old,  due  to  ovariotomy  twenty-seven 

years  before 521 

591.  A  section  through  the  constricted  portion  of  the  bowel  shown  in  Fig.  590       .         .        .  522 

592.  Showing  the  ends  of  the  tubes  and  pieces  of  the  ovary  left  after  an  imperfect  opera- 

tion       525 


LIST   OF   PLATES. 


PLATE  PAGE 

XL    Fig.  1.  Hydrosalpinx  simplex 199 

Fig.  3.  Hydrosalpinx  follicularis. 

XTI.     Hydrosalpinx  simplex 199 

Xni.     Hydrosalpinx  follicularis  (Fig.  1.  Plate  XI  magnified) 204 

XIV.     A  typical  pyosalpinx 209 

XV.     Section  of  a  small  nodule  taken  from  the  inner  surface  of  a  cysto-papilloma  of  the 

ovary  (Fig.  413) 2T0 

XVI.     A  papillary  ovarian  cyst  exhibiting  a  few  sarcomatous  nodules 275 

XVn.     Epithelioma  of  the  cervix .  309 

XVIII.     Radical  operation  for  cancer  of  the  uterus 321 

XIX.    Injected  specimen  showing  the  vascular  supply  of  myomata 338 

XX.     Angio-myoraa  of  the  uterus,  with  cystic  degeneration 382 

XXI.     Benign  adeno-rayoma  of  the  uterus 385 

XXII.     Benign  adeno-myoma  of  the  uterus ;  magnified  sections  of  Plate  XXI       .        .        .  387 

XXIII.  Diagnosis  of  extra-uterine  pregnancy  by  microscopic  examination      ....  448 

XXIV.  Pregnancy  in  a  rudimentary  left  uterine  horn  ;  magnified  sections  of  Fig.  533  .        .  464 

xiii 


OPERATIVE    GYNECOLOGY. 


CHAPTEE  XX. 

GENERAL    PRINCIPLES   AND    COMPLICATIONS   COMMON    TO   ABDOMINAL 

OPERATIONS. 

1.  Health  of  the  surgeon. 

2.  Examination  of  the  patient :  Lungs,  heart  and  circulation,  liver,  stomach,  family  history. 

3.  Urinalysis. 

4.  Preliminary  preparation  of  the  patient:  a.  To  produce  the  best  possible  physical  condition. 

b.  To  quicken  the  emunctories.     c.  To  secure  aseptic  surface  of  abdomen. 

5.  Preparation  of  patient  in  the  operating  room. 

6.  Preparation  of  surgeon  and  assistants. 

7.  Proper  dress  and  conduct  of  visitors. 

8.  Length  of  incision,  and  how  to  iind  the  peritoneum  :  a.  The  exploratory  incision,     h.  Cutting 

through  the  umbilicus,     c.  Hemorrhage  from  the  incision. 

9.  Exposure  of  the  field  of  operation  :  a.  Elevated  pelvis ;  advantages  and  disadvantages,     ft.  Hlu- 

mination. 

10.  Methods  of  dealing  with  adhesions  :  a.  Adhesions  to  pelvic  walls,  floor,  and  broad  ligaments. 

ft.  Omental  adhesions,  c.  Uterine  adhesions,  d.  Rectal  adhesions,  e.  Intestinal  adhe- 
sions. /.  Appendical  adhesions  and  removal  of  the  vermiform  appendix,  g.  Vesical 
adhesions. 

11.  Injuries  to  the  bladder  and  ureters. 

12.  Ligation  of  the  pedicle. 

1.3.  Hemorrhage  :  a.  Sources  of.     ft.  Control. 

14.  Irrigation  of  abdomen  with  normal  salt  solution. 

15.  Drainage.     1.  Physiology  of  drainage :   («)  Function  of  the  peritoneum  under  normal  and 

pathological  conditions,  (ft)  Mechanism  of  absorption  of  fluids  and  solid  particles  in 
the  peritoneal  cavity.  2.  Clinical  studies  of  the  subject.  3.  Objections  to  drainage. 
4.  The  prevention  and  removal  of  infection  without  resorting  to  drainage :  (a)  Postural 
drainage.     .5.  Cases  to  be  drained.     6.  How  to  put  in  and  take  out  a  gauze  drain. 

16.  Closure  of  the  incision. 

17.  The  abdominal  dressing. 

In  order  to  avoid  constant  repetition  in  discussinir  the  various  operative  pro- 
cedures as  they  are  taken  up,  I  propose  in  this  chapter  to  consider  certain  details 
common  to  tlie  technique  of  all  ahdominal  operations. 

The  Health  of  the  Surgeon. — The  surgeon's  physical  condition  has  much  to  do 
with  the  success  of  his  work.  I  would  insist  that  no  man  in  ill  health  is  justified 
in  doing  abdominal  surgery,  becau.se  he  is  not  in  condition  to  stand  the  great  and 
often  prolonged  strain  upon  his  attention,  with  the  constant  appeals  to  a  clear 
judgment  in  rapidly  deciding  questions  of  vital  importance.  ]\[oreover,  to  meet 
such  serious  emergencies  as  may  arise,  not  only  judgment  is  needed,  but  a  well- 
halanced  nervous  and  muscular  system,  which  are  not  at  the  disposal  of  an  in- 
valid. A  surgeon  who  is  affected  with  an  acute  tonsillitis,  pharyngitis,  ozena, 
41  1 


2         PRINCIPLES    AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 

alveolar  abscess,  furimculosis,  or  pulmonary  tuberculosis  should  consider  himself 
absolutely  debarred  from  performing  abdominal  operations  of  any  sort  on  ac- 
count of  the  danger  of  direct  infection  of  the  patient.  It  is  also  improper  for 
any  one  who  has  an  elevation  of  the  temperature  to  go  near  the  operating  table. 
A  suppurating  wound  of  any  part  of  the  hand  debars  the  surgeon,  assistant,  or 
nurse  from  operating  or  assisting  until  it  is  healed,  so  that  the  part  can  be  thor- 
oughly scrubbed. 

Examination  of  the  Patient. — Preceding  every  abdominal  operation  a  thorough 
physical  examination  must  be  made,  including  an  investigation  of  every  impor- 
tant organ  in  the  body.  It  is  best  to  do  this  by  taking  the  organs  up  in  some 
systematic  order,  which  should  not  be  deviated  from.  The  lungs  must  be  care- 
fully examined  for  tuberculosis,  the  pleural  cavities  for  fluid,  the  heart  for  valvu- 
lar lesions  and  evidences  of  fatty  degeneration,  the  arterial  system  for  sclerosis, 
the  urine  for  nephritis,  pyelitis,  or  diabetes,  and  the  liver  for  cirrhosis.  Gastric 
symptoms,  indicating  ulcer  of  the  stomach  or  carcinoma,  demand  attention. 
Close  inquiry  must  be  made  into  the  patient's  former  history  to  discover  any 
tendency  toward  insanity.  Women  who  have  been  in  an  asylum,  or  those  who 
have  at  times  appeared  mentally  unsound,  although  able  to  remain  at  home,  are 
peculiarly  prone  to  melancholia  or  even  violent  insanity  after  any  operation, 
whether  pelvic  or  abdominal.  In  one  case,  in  which  I  simply  repaired  the  peri- 
neum, the  patient,  who  was  markedly  emotional,  developed  a  profound  melan- 
cholia which  lasted  for  months.  Another  woman,  a  pronounced  neurasthenic, 
three  weeks  after  a  suspension  operation,  attempted  suicide  by  cutting  the  abdo- 
men with  a  broken  bottle,  although  up  to  this  time  she  had  shown  no  signs  of 
actual  insanity ;  about  two  months  later  she  succeeded  in  cutting  her  throat  with 
a  razor.  Cases  might  easily  be  multiplied,  but  this  subject  will  be  discussed 
more  fully  in  the  complications  following  operations. 

A  careful  preliminary  study  of  his  cases  after  this  fashion  is  of  paramount 
importance  to  the  operator,  for  unless  such  a  routine  examination  is  followed  out 
in  every  case,  now  and  then  a  life  will  be  lost  from  some  unsuspected  associated 
disease.  Disease  of  an  extrapelvic  organ,  sufficiently  advanced  to  cause  death 
independently  in  the  near  future,  forbids  any  but  an  emergency  operation.  This 
needs  not,  however,  prohibit  operations  for  pelvic  abscess  in  patients  with  pul- 
monary tuberculosis,  where  there  is  reason  to  believe  that  the  patient  may  live 
some  years  in  comparative  comfort,  if  the  pelvic  complication  is  removed.  Old 
age  also  forms  no  barrier,  as  the  results  of  careful  work  appear  almost  as  success- 
ful in  the  aged  as  in  the  young. 

It  is  my  habit,  in  referring  patients  from  a  consultation  or  from  my  private 
office  to  a  hospital  for  operation,  to  fill  out  one  or  more  of  the  headings  on  a 
chart  similar  to  the  following  one,  printed  on  a  sheet  of  paper  large  enough  to 
file  with  the  patient's  history.  Under  the  •'  preliminary  investigation  "  I  write 
any  notes  which  may  be  necessary  to  call  attention  to  certain  features  in  the 
general  examination  to  which  special  attention  should  be  given ;  as  a  rule,  the 
history  of  the  patient  lias  brought  out  some  good  reason  for  a  particularly  care- 
ful study  of  some  organ  or  organs,  which  is  emphasized  in  this  way. 


URIXALYSIS. 


It  is  also  important  to  note  at  once  just  what  surgical  procedures  a]3pear  to 
be  needed,  as  it  is  quite  possible,  now  that  so  many  operations  are  done  at  one 
sitting,  that  a  busy  surgeon  may  forget  one  or  more  where  several  are  indicated. 

OUTLINE   OF   PROPOSED   TREATMENT. 


Name,  Date, 


Preliminary  Investigation  of 

Operations  : 

Chest 

Tipper  Abdominal 

Digestion 

Pelvic 

Urine 

Appendix  vermiform  is. 

Kidneys 

Renal 

Blood 

Cervical 

Rectal 

Breast 

Urinalysis. — No  detail  in  the  preparation  of  a  patient  for  operation  is  more 
important  than  a  careful  examination  of  the  urine,  which  must  never  be  omitted. 
The  kidneys  are  the  most  important  emunctories  of  the  body,  and  their  function 
is  especially  taxed  after  an  operation  ;  it  is  therefore  essential  to  note  particularly 
the  way  they  act  beforehand,  both  as  a  test  of  present  efficiency,  as  a  guide  in 
deteraiiiiing  whether  or  not  to  do  an  operation,  and  to  afford  a  standard  of  com- 
parison after  the  operation,  should  their  activity  appear  impaired.  A  convales- 
cence is  often  impeded  by  unsound  kidneys ;  moreover,  every  pathologist  will 
attest  that  renal  lesions  are  commonly  brought  to  light  in  the  autopsies  on  women 
dying  from  gynecological  operations.  Out  of  twenty-nine  autopsies  made  upon 
cases  dying  in  my  service  at  the  Johns  Hopkins  Hospital,  nineteen,  or  65  per 
cent,  showed  some  kidney  lesion.  In  eight  there  was  a  chronic  diffuse  nephritis, 
in  eight  fatty  degeneration  and  cloudy  swelhng,  in  two  the  ureter  was  occluded 
by  a  ligature,  and  in  one  there  was  atrophy  of  one  kidney.  One  of  the  chronic 
nephritis  group  had  a  pyelitis  with  calcareous  incrustation  of  the  papillte  of  the 
pyramids,  and  one  of  the  two  cases  with  an  occluded  ureter  had  a  hydronephrosis 
on  the  occluded  side  and  a  pyonephrosis  of  the  other  side.  The  first  of  these 
cases  died  some  months  after  a  hysterectomy  and  removal  of  both  ovaries  and 
tubes  for  carcinoma  uteri  and  dermoid  cyst,  by  extension  of  the  cancerous  dis- 
ease. 

Only  in  the  two  cases  with  ligatured  ureters  was  the  renal  condition  the  cause 
of  death ;  it  must  be  borne  in  mind  that  fatty  degeneration  and  cloudy  swelling 
are  almost  always  due  to  the  peritonitis,  and  are  therefore  a  part  of  tlie  infec- 
tion, and  secondary  to  it,  and  must  not  be  taken  into  account  in  explaining  the 
cause  of  death. 


4         PKIXCIPLES   AND    COMPLICATIONS    COMMON   TO    ABDOMINAL    OPERATIONS. 

In  none  of  my  cases  was  the  chronic  nephritis  far  advanced,  and  in  no  in- 
stance could  I  attribute  the  death  directly  to  this  source,  although,  as  shown  by 
Dr.  Simon  Flexner  in  a  recent  research  on  terminal  infections,  lesions 
of  the  kidney  may  impair  the  powers  of  resistance,  and  thus  allow  certain  organ- 
isms to  gain  a  foothold  and  cause  a  fatal  termination. 

A  knowledge  of  the  condition  of  the  kidneys  is  of  eminent  practical  value 
for  the  following  reasons : 

First,  that  we  may  refuse  to  operate  upon  cases  presenting  advanced  renal 
lesions. 

Second,  that  we  may  delay  the  operation  in  less  serious  cases  until  these 
emunctories  are  brought  into  the  best  possible  condition  by  careful  preparatory 
treatment. 

Third,  that  we  may  adopt  unusual  precautions  in  the  course  of  operations 
upon  cases  complicated  by  a  kidney  disease. 

Fourth,  that  we  may  watch  such  cases  carefully  throughout  their  convales- 
cence, avoiding  opiates  or  other  drugs  which  tend  to  check  the  secretion,  and 
that  we  may  assist  impaired  kidneys  by  throwing  the  stress  of  excretion  as  much 
as  possible  upon  the  skin  and  bowels. 

It  is  my  practice  in  major  operative  cases  to  have  several  urinalyses  made, 
first,  two  or  three  days  before  operation,  then  shortly  after  it  to  determine 
whether  any  disturbance  has  been  produced  by  the  operation,  and  again  when 
the  patient  gets  out  of  bed,  usually  about  the  twenty -first  day,  to  see  if  any  dis- 
turbances previously  found  have  disappeared. 

To  avoid  contamination  by  leucorrheal  or  menstrual 
discharges,  the  bladder  is  catheter ized;  this  is  usually  done  in 
the  early  morning,  because  the  night  urine  a23proximates  the  diurnal  average  in 
its  physical  characteristics. 

To  determine  accurately  the  difference  between  catheterized  and  voided 
specimens  of  urine,  I  made  a  series  of  thirty  analyses  of  each  kind,  with  the  fol- 
lowing result :  Nine  of  the  voided  specimens  showed  albumin,  while  the  cathe- 
terized urine  from  the  same  patients  showed  none.  In  all  the  nine  cases  the 
patients  had  a  leucorrheal  discharge,  showing  the  source  of  contamination.  It  is 
evident  from  this  that  reliance  can  only  be  placed  upon  catheterized  specimens, 
and  no  examination  revealing  the  presence  of  lesser  grades  of  albuminuria  can 
be  considered  final  until  it  is  controlled  in  this  way. 

The  best  receptacle  for  the  urine  to  be  examined  is  a  conical  glass  graduate, 
which  quickly  shows  the  presence  of  any  sediment. 

The  analysis  should  include  a  description  of  the  physical  characteristics  of 
the  urine,  the  presence  of  sediment,  its  specific  gravity  and  reaction,  the  pres- 
ence of  albumin  or  sugar,  the  average  daily  amount  of  urine  passed,  the  percent- 
age of  urea,  and  the  microscopical  appearances.  It  is  best  to  record  each  exami- 
nation in  a  book  of  urinary  charts,  whose  sei)arate  leaves  can  be  torn  out  and 
filed  with  the  history  of  the  case,  leaving  a  duplicate  stub  in  the  book.  I  give 
here  the  chart  which  I  use  in  my  own  work. 


URINALYSIS. 


No.. 


Nam,e. 


AIS^ALYSIS   OF  URINE. 
Date. 
Diagnosis 


Mixed. 


Date. 

Amount. 

Time. 

Ch  aracteristics. 

Albumin. 

Sugar. 

Urea. 

Microscope. 

Color 
Reaction 
Spec.  grav. 
Sediment 

Color 
Reaction 
Spec.  grav. 
Seditnent 

Color 
Reaction 
Spec.  grav. 
Sediment 

The  heat  test,  and  Heller's  nitric-acid  test,  are  sufficiently  delicate  and  are  the 
best  to  detect  albumin.  I  used  trichloracetic  acid  at  one  time  extensively,  but 
found  it  unnecessarily  sensitive,  giving  evidence  of  percentages  of  albumin  too 
minute  for  practical  purposes. 

Fehling's  solution  is  the  best  for  the  detection  of  sugar.  I  have  found 
sugar  in  the  urine  in  but  three  out  of  a  thousand  uri- 
nary examinations  in  gynecological  surgical  cases;  in  two 
the  amount  was  small  and  transient  and  did  not  prevent  an  operation ;  the  third 
case  was  one  of  complete  tear  of  the  recto-vaginal  septum.  Upon  discovering 
the  sugar  all  idea  of  performing  an  operation  was  abandoned,  and,  in  spite  of 
appropriate  treatment  for  the  diabetes,  the  })atient  died  in  coma  a  few  weeks  later. 

Out  of  twelve  hundred  examinations  of  the  urine  I  have  never  seen  glyco- 
suria arise  after  an  operation. 

From  a  careful  study  of  five  hundred  urinary  charts  of 
my   abdominal   cases   I   deduced    the   following  rules: 

First,  no  case  of  advanced  nephritis  should  be  subjected  to  an  abdominal 
operation  of  greater  gravity  than  a  simple  tapping  of  a  cyst  or  an  ascites. 


6  PRIXCIPLES    AND    COMPLICATIONS    COMMON    TO    ABDOMINAL    OPERATIONS. 

Second,  women  with  a  marked  amount  of  albumin  in  the  urine  should  he 
carefully  watched  for  a  time,  and  if  the  alljumin  persists  no  serious  operation 
which  is  not  imperative  should  he  performed.  Epithelial  and  blood  casts,  asso- 
ciated with  the  albumin,  increase  the  gra^dtj  of  the  outlook. 

Third,  hyaline  and  granular  casts  do  not  contraindicate  operation  unless 
numerous  and  persistent.  Albumin  is  found  in  23  per  cent  of  all  cases,  and 
casts  in  5  per  cent. 

Fourth,  vascular  changes,  high-tension  pulse,  and  heart  hypertrophy  must 
always  be  looked  for.  These  alterations  become  serious  when  associated  with 
casts  and  albumin  in  the  urine. 

Fifth,  a  marked  diminution  in  the  excretion  of  urea  in  twenty-four  hours, 
associated  with  a  small  amount  of  albumin  or  a  few  casts,  must  be  regarded  as 
of  serious  import. 

Sixth,  pus  in  the  urine,  amounting  to  more  than  a  trace,  is  of  serious  signifi- 
cance, and  its  source  must  be  determined  before  operation.  This  will  occasion- 
ally be  found  to  come  from  an  unsuspected  pyelitis  or  pyelonephritis. 

Se\'enth,  sugar  must  always  be  looked  for ;  if  scant  and  transient  it  may  be 
disregarded,  but  if  persistent  no  major  operation  should  be  performed. 

It  will  be  seen  by  the  third  rule  that  a  small  amount  of  albumin  and  a  few 
granular  and  hyaline  casts  need  not  prevent  an  operation.  On  the  contrary, 
such  minor  renal  changes  are  observed  in  a  large  percentage  of  all  g}^lecological 
cases,  and  are  often  directly  dependent  upon  the  jjresence  of  a  pelvic  tumor,  in 
which  case  the  renal  complication  actually  constitutes  an  im- 
portant indication  for  the  operation.  In  cases  of  large  cysto- 
mata  and  fibroid  tumors  I  have  often  seen  the  albumin  disappear  entirely 
within  two  weeks  after  the  removal  of  the  mass.  In  sixty-six  of  my  cases 
with  simple  albuminuria  no  untoward  renal  symptoms  were  observed  after 
operation. 

When  an  operation  is  determined  upon  in  the  presence  of  renal  changes  the 
operator  will  diminish  the  tendency  to  shock  and  tax  the  lessened  vitality  of  the 
patient  as  little  as  possible  by  avoiding  all  delays,  by  proceeding  promptly  with 
his  work  as  soon  as  the  patient  is  anesthetized,  by  taking  all  possible  precau- 
tions to  avoid  shock  during  the  operation,  by  the  external  application  of  heat 
and  avoidance  of  exposure  of  the  \dscera,  and  by  calling  upon  the  bowels  and 
skin  for  active  supplemental  service  as  soon  as  possible  after  it. 

There  is  a  definite  causal  relationship  between  certain 
classes  of  gynecological  cases  and  certain  ureteral  and 
renal   affections    which   is   in   general   as   follows: 

Myomata  in  many  instances  press  upon  the  ureters,  inducing  hydroureter 
and  hydronephrosis.  This  is  particularly  the  case  in  subperitoneo-jDelvic  myo- 
mata lifting  up  and  displacing  the  pelvic  portions  of  the  ureters  into  the  abdo- 
men. One  patient  died  in  the  ward  without  any  operation  at  all,  with  a  pyelo- 
nephritis caused  by  a  myomatous  uterus  choking  the  pelvis  and  abdomen. 

I  have  seen  pelvic  abscess  associated  with  a  pyelonephritis  of  the  same  side 
causing  death.     Although  constantly  looking  for  it,  I  have  seen  but  one  case  of 


PRELIMINARY    PREPARATIOX    OF   THE    PATIEXT.  7 

extensive  amyloid,  degeneration  associated  Avith  pelvic  suppuration,  and  that 
patient  was  svphilitic.  In  view  of  the  impression  created  by  the  older  litera- 
ture on  this  subject,  the  absence  of  amyloid  degeneration  in  so  large  a  number 
of  chronic  pus  cases  is  certainly  noteworthy,  and  dread  of  its  occurrence  ought 
not  to  be  such  a  bugbear  to  gynecologists. 

Carcinoma  of  the  cervix  in  its  advanced  stages  compresses  the  ureters  and 
produces  hydronephrosis  and  death  from  uremia  in  a  large  percentage  of  cases. 
Of  eight  inoperable  carcinoma  cases  in  which  an  autopsy  was  made,  two  showed 
one  ureter  very  greatly  enlarged  with  associated  hydronephrosis,  while  the  other 
cases  showed  a  very  great  distention  of  both  ureters  and  kidneys  (see  Chapter 
XXXj.  In  five  of  these  cases  the  patients  showed  marked  symptoms  of  uremia 
for  days  and  even  weeks  before  death,  and  for  the  last  few  days  before  the  end 
came  were  in  profound  coma. 

Preliminary  Preparation  of  the  Patient. — The  object  in  view  in  preparing  the 
patient  is  threefold  :  First,  to  bring  her  into  the  best  physical  condition  possible ; 
second,  to  quicken  her  emunctories,  and  secure  a  thorough  evacuation  of  the 
intestinal  tract ;  and  third,  to  secure  as  nearly  as  possible  an  aseptic  condition 
of  the  skin  of  the  abdomen  adjacent  to  the  line  of  incision. 

The  exact  amount  of  preparation  which  it  is  best  to  devote  to  any  given  case 
preceding  celiotomy  will  vary  with  the  mdely  varjdng  conditions  of  the  pa- 
tients. When  the  general  health  is  good  but  one  or  two  days  are  needed,  de- 
voted chiefly  to  the  thorough  evacuation  of  the  intestinal  tract  and  the  disin- 
fection of  the  abdominal  skin.  In  urgent  cases,  such  as  Cesarean  section  in  an 
exhausted  patient,  all  preliminaiy  preparations  must  be  dispensed  with,  and  the 
abdomen  cleansed  for  the  first  and  only  time  within  the  few  minutes  immedi- 
ately 2? receding  the  operation. 

Cases  of  ruptured  cysts  with  hemorrhage,  ruptured  pelvic  abscess,  ileus, 
appendicitis,  ruptured  ectopic  gestation  sac,  in  which  the  general  condition  is 
rapidly  growing  worse,  should  be  operated  upon  as  speedily  as  possible,  utilizing 
any  little  intervening  time  in  stimulating  the  patient  with  hypodermics  of 
strychnin,  doses  of  brandy,  and  rectal  enemata. 

In  private  practice  the  gra\dty  of  the  patient's  symptoms  may  even  demand 
a  sacrifice  of  some  of  the  important  details  in  the  aseptic  technique.  The  oper- 
ator, ftjr  example,  may  be  obliged  under  these  circumstances  to  make  use  of  hot 
water  from  the  spigot,  and  vessels  which  have  only  been  scalded  out.  The 
preparation  of  the  room  will  often  be  imperfect,  and  it  may  even  be  found  ne- 
cessary to  cleanse  a  dirty  abdomen  just  befoi-e  beginning  the  operation. 

Poor  women  with  abdominal  tumors,  pelvic  al)scess,  or  other  inflannnatory 
disease,  who  are  in  a  depressed,  run-down  condition,  and  who  have  only  laid 
aside  the  burden  of  exacting  household  duties  and  family  cares  just  as  they 
entered  the  hospital,  improve  remarkably  upon  giving  them  one  or  two  weeks 
of  preparatory  treatment  with  absolute  rest  in  ])ed,  nutritious  diet,  tonics? 
and  mild  stimulation  in  the  shape  of  koumiss  and  malt.  Daily  baths  and  rub- 
bing with  alcohol  are  valuable  adjuvants  in  bringing  back  much  of  the  lost 
tone. 


8         PKINCIPLES    AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 

Patients  who  are  greatly  depressed  physically  by  prolonged  or  chronic  ill- 
ness show  a  greater  susceptibility  to  infection  than  the  strong  and  robust.  As 
an  instance  of  this  statement,  in  the  last  twenty  cases  of  cancer  of  the  uterus 
operated  upon  by  the  abdominal  method,  50  per  cent  have  had  varying  de- 
grees of  local  suppuration  of  the  abdominal  wound,  varying  from  a  slight  dis- 
charge of  pus  to  an  extensive  breaking  down  of  the  wound. 

The  admirable  paper  of  Dr.  Simon  Flexner,  upon  terminal  infec- 
tions, bears  directly  on  this  point.  In  an  exhaustive  analysis  of  the  autop- 
sy records  of  cases  dying  in  the  Johns  Hopkins  Hospital,  he  found  that  patients 
suffering  with  chronic  heart  lesions,  nephritis,  and  other  long-standing  ail- 
ments were  in  a  great  proportion  of  cases  carried  off  by  some  terminal  infec- 
tion. In  other  words,  the  decrease  of  vital  resistance  occasioned  by  the  pro- 
longed illness  simply  paved  the  way  for  a  terminal  infection  which  then  easily 
carried  the  patient  off. 

In  the  light  of  this  instructive  paper  all  patients  Avith  any  form  of  chronic 
disease  should  be  brought  into  the  best  possible  physical  condition  by  appro- 
priate tonic  treatment  before  being  subjected  to  any  serious  operation. 

In  the  pre-antiseptic  days  no  surgeon  felt  justified  in  proceeding  with  an 
operation  without  at  least  two  weeks'  to  a  month's  preliminary  treatment. 
When  healing  jper  primam  was  so  exceptional  and  "  laudable  pus "  so  much 
desired,  the  jjractical  sense  of  the  early  surgeons  taught  them  to  first  surround 
their  patients  with  the  best  possible  conditions  for  increasing  their  powers  of 
resistance  before  proceeding  with  an  operation. 

Extremely  nervous  patients  require  peculiar  management,  and  the  operation 
should,  as  a  rule,  be  performed  within  one  or  two  days  after  the  announcement 
of  its  necessity  has  been  made,  in  order  to  lessen  the  drawbacks  of  wakeful 
nights,  disturbed  digestion,  and  nervous  apprehensions. 

If  the  patient  can  be  prepared  for  operation  without  suspecting  it,  I  some- 
times announce  it  just  as  I  am  ready  to  give  the  anesthetic.  In  such  a  case  it  is 
imj)ortant  to  have  a  clear  understanding  with  the  relatives  or  a  responsible 
attending  physician. 

The  best  general  rule  is  to  take  four  days  to  make  all  the  necessary  immedi- 
ate preparations. 

The  bowels  must  be  regulated,  and  there  must  be  a  thorough  evacua- 
tion of  the  whole  intestinal  tract  just  before  the  operation.  The  presump- 
tion in  all  pelvic  tumor  cases,  even  though  they  complain  of  diarrhea,  is  that 
a  fecal  stasis  exists  in  the  large  bowel,  and  the  surgeon  should  not  decide  to 
the  contrary  before  taking  the  history,  making  an  examination  of  the  rectum 
through  the  vagina,  and  palpating  the  abdomen  to  determine  the  condition  of 
the  sigmoid  flexure  and  colon.  Tympany  is  one  of  the  most  embarrassing  com- 
plications, and,  in  an  extreme  form,  even  contraindicates  operation.  It  must 
therefore  first  be  carried  off  by  active  purgation,  associated  with  the  use  of  car- 
minatives and  bismuth.  The  old-fashioned  black  draught  is  an  efficient  saline 
purge,  and  the  carminative  combined  with  it  tends  to  prevent  any  griping.  The 
following  is  the  formula : 


PREPARATION    OF   THE    PATIENT    IN    THE    OPERATING    ROOM.  9 

]^  Magnes.  sulpli 3  j  ; 

Fol.  sennffi 3  iij  ; 

Mannse 3  ij  ; 

Pulv.  cardam.  sem 3  j  ; 

Aq.  biillient O  j. 

Boil,  strain,  and  give  two  ounces  every  two  hours. 

Vaginal  douches  of  a  saturated  solution  of  boric  acid  or  a  2  per  cent  car- 
bolic-acid solution  should  be  given  twice  a  day  before  operation  if  the  patient 
has  an  offensive  or  purulent  discharge ;  otherwise  they  are  omitted. 

On  the  preceding  evening  a  general  warm  bath  is  given.  From  twelve  to 
eighteen  hours  beforehand  a  purgative  dose  of  citrate  of  magnesia,  castor  oil, 
Epsom  salts,  licorice  powder,  or  a  pill  of  aloes,  strychnin,  and  belladonna  is 
given,  followed  early  the  next  morning  by  a  rectal  enema.  A  free  purgation 
quickens  the  absorptive  activities  of  the  peritoneum  immediately  after  the  opera- 
tion, and  so  promotes  the  speedy  removal  of  blood  and  debris. 

After  the  patient's  bowels  are  thoroughly  evacuated,  if  necessary  using  a 
second  enema  to  effect  it,  she  is  prepared  for  the  operation. 

In  order  that  the  field  of  operation  may  be  rendered  as  aseptic  as  possible 
before  the  patient  is  taken  to  the  operating  room,  the  most  active  disinfectant 
measures  are  employed. 

All  of  the  articles  necessary  to  the  cleansing  of  the  abdomen  are  placed  in 
convenient  reach.  Usually  a  small  stand  is  placed  near  the  bed,  and  upon  this 
are  placed  green  soap,  flasks  of  water  and  of  bichloride  solution  (1-1,000),  a 
package  of  sterile  towels,  gauze  scrubbing  mops,  alcohol,  and  ether. 

The  abdomen  is  well  exposed,  the  bed  and  clothing  above  and  at  the  sides 
being  protected  by  a  rubber  sheet.  The  skin  from  the  ensiform  to  just  above 
the  pubes  is  lathered  with  green  soap  and  water,  and  shaved  well  out  from  the 
median  line.  If  the  abdominal  incision  is  to  be  made  in  any  other  locaHty  than 
the  median  line  the  nurse  is  so  instmcted,  and  varies  the  shaving  to  suit  the  site 
of  operation.     After  shaving,  the  skin  is  thoroughly  scrubbed  with  a  gauze  mop. 

In  the  case  of  a  nervous,  delicate,  refined  woman,  the  shaving  would  better 
be  done  on  the  operating  table  when  she  is  unconscious. 

The  nurse  now  suspends  the  preparation  while  she  disinfects  her  own  hands, 
after  which  the  skin  is  thoroughly  rubbed  and  washed  with  alcohol,  then  ether, 
and  finally  with  a  1-1,000  bichloride  of  mercury  solution. 

A  large  sterile  gauze  shield  is  tied  by  conveniently  placed  tapes  over  the  ab- 
domen, and  the  patient's  toilet  is  completed  by  putting  on  a  clean  nightgown. 
If  she  is  nervous  or  feels  weak,  a  wine  glass  of  sherry  or  a  small  milk  punch 
may  be  given. 

Preparation  of  the  Patient  in  the  Operating  Eoom. — The  anesthetic  should  be 
administered  in  a  room  adjoining  the  operating  room,  arranged  as  much  as 
possible  like  an  ordinary  bedroom,  so  that  the  patient  may  not  have  the  dis- 
tress of  witnessing  any  of  the  preparations.  The  most  satisfactory  anesthetizing 
couch  in  a  hospital  is  the  carriage  upon  which  she  has  been  brought  from  the 
ward.     "When  unconscious  she  may  be  transferred  to  the  operating  table  and 


10       PRIXCIPLES   AXD    COMPLICATIONS    COMMON   TO    ABDOMINAL    OPERATIONS. 

placed  with  her  hips  resting  on  the  ovariotomy  pad,  so  that  its  lower  border 
reaches  about  15  centimeters  (6  inches)  below  the  vulva,  and  the  upper  border 
lies  well  above  the  abdomen ;  a  self -draining  table  in  a  hosjDital  does  away  with 
the  necessity  of  using  the  pad. 

The  first  step  towai-d  disinfection  in  all  abdominal  cases  after  the  patient  is 
put  upon  the  table  is  the  thorough  cleansing  of  the  vagina  by  raising  and  sepa- 
rating the  legs  and  applying  soap  and  warm  water  vigorously,  with  a  bunch  of 
sterilized  cotton  held  in  the  grasp  of  a  pair  of  long  dressing  forceps.  This  step 
need  not  be  carried  out  in  a  young  woman  with  an  intact  hymen.  A  large  fun- 
nel or  an  open  sj^eculum  may  be  placed  between  the  thighs  close  to  the  body  to 
facilitate  drainage  of  fluids  running  down  from  the  abdomen  onto  the  pad.  The 
patient's  clothes  are  drawn  well  above  the  ui)per  border  of  the  pad,  her  arms  are 
flexed  and  folded  on  the  chest,  and  retained  in  this  position  by  the  undervest 
being  pulled  up  over  them,  and  by  tying  the  wrists  together  with  a  gauze  ban- 
dage. The  chest  is  protected  by  a  blanket  with  a  rubber  sheet  over  it,  and  the 
legs  warmly  wrapped  in  a  blanket  and  a  sheet  in  like  manner.  If  the  ojDeration 
is  to  be  long,  the  feet  should  rest  upon  a  hot-water  bag,  and  another  be  placed 
under  the  knees,  and  still  others  about  the  chest.  For  feeble  patients  I  use  long, 
narrow,  hot-water  bags  encased  in  flannel  and  reaching  from  the  armpits  to  the 
knees. 

Cleansing  the  Abdomen. — The  temporary  protective  gauze  band- 
age, referred  to  above,  is  now  removed  by  the  nurse,  and  an  assistant,  with 
sterilized  hands,  proceeds  to  scrub  the  abdomen  with  sterilized  cotton  balls  en- 
veloped in  gauze,  applying  soap  and  water  freely  for  several  minutes.  Especial 
care  should  be  observed,  both  in  the  preliminary  preparation  in  the  ward  as 
well  as  upon  the  operating  table,  in  cleansing  the  folds  of  the  umbilicus,  where 
it  is  deep  using  some  absorbent  cotton  held  in  forceps.  Following  the  soap 
and  water,  the  abdomen  is  scrubbed  with  alcohol,  and  after  this  with  ether,  and 
finally  with  a  bichloride  solution  (1-1,000). 

Before  disinfecting  the  abdomen  of  unusually  fat  women,  the  creases  formed 
by  the  overhanging  cutaneous  folds  should  be  inspected  for  a  slight  dermatitis  or 
an  eczema,  which  often  exists,  and  unless  the  operation  is  imperatively  demanded, 
these  areas  should  be  entirely  healed  before  an  incision  is  made  through  the 
abdomen,  as  such  apparently  insignificant  surface  lesions  may  conceal  virulent 
organisms. 

In  one  patient,  a  woman  with  thick  abdominal  walls,  upon  whom  I  ojjerated, 
a  superficial  eczema  was  noted  at  the  time,  but  was  not  considered  dangerous  be- 
cause of  the  thorough  disinfection.  Notwithstanding  these  precautions,  the 
patient  died  of  a  virulent  infection  with  suppuration  of  the  abdominal  wound, 
which  extended  into  the  peritoneum.  When  we  consider  the  fact  that  the 
staphylococcus  epidermidis  alb  us  has  its  normal  habitat  in  the 
deeper  layers  of  the  corium,  it  is  reasonable  to  infer  that  in  an  eczematous  patch 
in  one  of  the  deep  folds  of  the  abdomen,  which  is  subjected  to  constant  friction, 
there  may  be  deeply  underlying  infected  areas  uninfluenced  by  the  most  radical 
disinfecting  measures. 


PKOPER    DRESS   AXD    CONDUCT    OF   VISITORS.  11 

Arranging  the  Field  of  Operation , — Sterilized  towels  are  now 
laid  upon  the  rubber  sheets  on  the  chest  and  thighs  and  on  the  sides  of  the  ab- 
domen, completely  covering  them  ;  a  piece  of  sterilized  gauze,  four  layers  thick 
and  1  meter  (1  yard)  square,  or  a  sheet  made  for  the  purpose  with  a  hole  in  the 
middle,  is  laid  over  the  patient  from  breast  to  knees ;  finally  two  sterilized 
towels  are  spread  above  and  below  over  the  ends  of  the  cover.  A  wire  bracket 
resting  on  the  patient's  thighs  and  covered  with  sterilized  towels  serves  as  a  con- 
venient receptacle  for  the  instruments  which  the  operator  needs  to  have  close  at 
hand  if  the  operation  is  done  with  the  patient  in  the  horizontal  posture.  I 
provide  for  this  when  the  pelvis  is  elevated  by  turning  over  the  end  of  a  towel 
stretched  across  the  thighs  and  clamping  it  to  the  sheet  so  as  to  make  a  shallow 
pocket,  ill  which  the  instruments  rest  without  slipping  down. 

Preparation  of  Surgeon  and  Assistants. — During  the  preparation  of  the  patient, 
which  is  made  by  a  trustworthy  assistant,  the  surgeon  cleanses  and  disinfects  his 
hands  according  to  the  method  described  in  Chapter  I,  page  20. 

Having  completed  the  disinfection  of  his  hands,  the  surgeon  begins  the 
operation  by  cutting  an  opening  in  the  gauze  diaphragm,  leaving  the  abdomen 
and  surrounding  parts  protected  by  it. 

After  the  operation  is  begun  it  must  be  the  constant  effort  of  the  surgeon 
and  his  assistants  to  prevent  the  importation  of  any  infectious  matter  from  the 
outside.  To  this  end  contact  wnth  unsterilized  objects  must  be  rigorously 
avoided,  and  should  it  be  necessary  to  use  the  cautery  or  other  instruments 
which  can  not  be  rendered  aseptic,  the  hands  are  protected  by  small  squares  of 
sterilized  gauze,  which  are  thrown  away  immediately  after  use.  The  aseptic 
field  is  confined  to  the  sterilized  instruments,  sponges,  and  ligatures,  and  the 
protected  abdomen  of  the  patient,  and  should  the  operator,  by  accident  or  un- 
avoidably, step  outside  of  this  field  and  be  contaminated,  the  error  in  technique 
must  at  once  be  corrected  by  scrubbing  the  hands  for  a  minute  and  immersing 
them  again  in  the  l)ichloride-of -mercury  solution  (1-1,000). 

Proper  Dress  and  Conduct  of  Visitors. — Few  operations  are  performed  in  our 
large  hospitals  without  the  presence  of  visitors,  who  often  act  as  a  jileasant 
stimulus  to  the  operator  to  do  his  best  work  and  whose  presence  is  in  no  way 
detrimental  to  the  patient. 

To  prevent  the  possil)]e  introduction  of  infectious  matter  from  outside  pro- 
fessional work,  visitors  should  be  required  to  wear  fresh  long  linen  dusters. 
This  precaution  not  only  covers  in  the  street  dust  from  their  garments,  but, 
by  putting  the  visitor  in  uniform,  as  it  were,  serves  as  a  constant  reminder 
of  his  relation  to  the  operation  and  the  sterilized  objects  of  the  operating 
room. 

Bystanders  should  keep  their  dusters  buttoned  and  their  hands  at  their  sides 
or  in  their  pockets,  and  under  no  circumstances  should  they  pick  up  or  touch 
anything,  or  attempt  to  assist  in  any  Avay  unless  requested  to  do  so.  If  allowed 
to  step  near  enough  to  inspect  the  Avound  closely,  they  must  be  cautioned  not 
to  let  their  clothes  touch  the  operating  table  or  the  patient,  and  not  to  bring 
their  heads  directly  over  the  wound,  or  to  breathe  into  it,  or  to  speak  over  it. 


12       PRINCIPLES   AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 

Visitors  and  students  also  should  not  use  tlie  same  wash  basins  and  towels  as 
the  operator  and  his  assistants. 

The  Length  of  the  Incision,  and  how  to  find  the  Peritoneum. — As  to  the  length 
of  the  incision,  the  best  rule  is  to  make  it  long  enough  for  the  operator  to  work 
as  rapidly  as  is  consistent  with  proper  attention  to  details.  Too  long  an  incision 
embarrasses  the  operator  by  permitting  the  escape  of  the  bowels  at  its  upper 
angle,  while  one  that  is  too  short  hampers  every  movement  and  prevents  a 
proper  inspection  of  the  field  as  the  operation  progresses.  It  was  a  tendency 
of  some  of  the  earliest  operators  to  make  enormous  incisions.  Sir  Spencer 
Wells  shows  in  his  book  {On,  Ovarian  and  Uterine  Tumors^  London,  1882,  p. 
294)  that  his  percentage  of  mortality  in  cases  in  which  the  incision  did  not 
exceed  six  inches  was  20*65,  while  the  percentage  in  cases  exceeding  six  inches 
was  39*43.  But  with  true  surgical  insight  he  infers  correctly  "  that  the  extent 
of  the  incision  is  httle  less  than  an  indication  of  the  gravity  of  the  case,  as  it 
can  not  be  supposed  that  two  or  three  inches,  more  or  less,  of  simple  division 
of  the  parietes  of  the  abdomen  would  augment  the  danger  to  this  amount."  In 
genera],  an  incision  4  centimeters  (1^  inch)  in  length  may  be  called  short,  and 
of  from  8  to  12  centimeters  (3  to  5  inches)  medium,  and  beyond  this  long.  The 
operator  must  never  allow  the  shortness  of  the  incision  to  restrict  his  manipula- 
tions within  the  abdomen.  Diflicult  operations — such  as  the  removal  of  large 
adherent  tumors,  pelvic  abscess,  and  other  inflammatory  masses — require  a  longer 
incision  to  facilitate  inspection  of  the  field  as  well  as  the  freer  use  of  the  hand  in 
the  abdomen. 

Exploratory  Incision  . — The  short  incision,  made  for  the  evacuation 
of  ascitic  fluid  and  for  an  exploration  of  the  peritoneal  cavity,  need  not  be  more 
than  3  to  4  centimeters  in  lengtli.  After  the  abdomen  is  collapsed  by  the  escape 
of  the  fluid,  one  or  two  fingers  may  then  be  introduced  for  the  purpose  of  ex- 
ploring the  pelvis  and  neighboring  viscera.  By  enlarging  the  incision  upward 
the  whole  hand  may  be  inserted  and  all  the  important  abdominal  organs — stom- 
ach, spleen,  liver,  gall  bladder,  pancreas,  omentum,  mesentery,  aorta,  kidneys, 
vermiform  appendix,  pelvic  viscera,  etc. — systematically  examined.  The  length 
of  the  incision  for  suspension  of  the  uterus  is  also  not  more  than  3  or  4  centi- 
meters. 

Incision  in  Fat  Women . — If  the  abdominal  walls  are  fat  the  incision 
must  be  longer,  because  the  great  thickness  of  the  parietes  renders  more  diflicult 
every  manipulation  within  the  cavity.  In  rare  cases  of  enormous  accumulation 
of  fat  (adiposus,  lipomatosus),  in  which  the  diagnosis  is  obscure,  great  advantage 
will  be  gained  and  danger  of  suppuration  in  the  convalescence,  or  of  hei-nia 
afterward,  avoided  by  making  an  exploratory  incision  through 
the  umbilical  ring,  where  the  abdominal  wall  is  thinnest  from  the 
absence  of  fat  and  muscular  tissue  between  the  skin  and  peritoneum.  By 
adopting  such  a  procedure  we  may  avoid  making  an  incision  through  a  fat 
wall  20  to  30  centimeters  (8  to  12  inches)  thick.  I  operated  in  this  way  upon 
a  patient  of  Dr.  G.  W.  Guthrie,  of  AVilkesbarre,  Pa.,  whose  weight  was  consid- 
erably over  three  hundred  pounds.     In  order  to  tap  her  for  an  ascitic  accumu- 


THE   LENGTH    OF   THE    INCISION,   AND    HOW   TO    FIND   THE    PERITONEUM.        13 

lation,  Dr.  Guthrie  had  been  obhged  to  have  a  trocar  made  14  inches  long,  and 
this  barely  reached  through  the  fat  walls.  At  the  operation  I  made  an  incision, 
10  centimeters  (4  inches)  long,  through  the  umbilicus  and  explored  the  whole 
peritoneal  cavity,  introducing  the  entire  arm.  It  was  fortunate,  indeed,  that  I 
adopted  this  plan  and  did  not  make  the  incision  lower  down,  as  the  patient  got 
out  of  bed  as  soon  as  she  regained  consciousness  and  refused  to  return  to  it  again 
even  at  night. 

In  cases  in  which  there  is  a  tumor  within  the  abdomen  the  length  of  the 
incision  is  determined  in  the  following  manner :  When  the  operator  is  uncertain 
as  to  the  exact  character  of  the  operation,  it  is  best  to  begin  by  making  a  small 
incision,  beginning  about  3  centimeters  (1^  inch)  above  the  symphysis,  and 
then,  if  necessary,  to  enlarge  it  by  using  the  index  and  middle  fingers  of  the  left 
hand  to  lift  up  the  abdominal  wall  from  the  intestines,  while  cutting  upward  in 
the  linea  alba  with  a  knife  or  stout  blunt-pointed  scissors.  A  large  monocystic 
ovarian  or  parovarian  tumor  may  often  be  evacuated  and  easily  drawn  out  of  a 
little  incision,  provided  there  are  no  adhesions  or  secondary  masses  which  can 
not  be  reduced  in  size.  An  adherent  cyst,  on  the  other  hand,  may  call  for  an 
extension  of  the  incision  up  through  the  umbilicus.  Small  non-adherent  ovarian 
and  tubal  enlargements  can  easily  be  turned  out  through  an  incision  4  to  6  centi- 
meters (1^  to  2h:  inches)  long. 

Pelvic  abscesses  require  a  longer  incision,  8  to  10  centimeters  (3  to  4  inches), 
to  give  a  better  exposure  and  facilitate  the  tapping  and  enucleation  of  the  pus 
sac  and  the  final  inspection  and  cleansing  of  the  pelvis. 

In  making  a  long  incision  I  prefer  to  cut  directly  through  the  umbilicus, 
and  then,  keeping  a  little  to  the  left  above  it,  to  avoid  the  suspensory  ligament 
of  the  liver ;  in  closing  this  incision  the  tissue  at  the  umbilicus  should  be  split 
on  each  side  to  gain  a  broader  surface  for  approximation. 

Myomatous  uteri  and  other  large  solid  or  semisolid  tumors  require  an  inci- 
sion, in  proportion  to  their  size,  large  enough  to  permit  the  mass  to  be  turned 
out  onto  the  abdominal  Avail  by  its  small  axis  without  diminution. 

In  making  the  incision  the  operator  first  fixes  the  median  line  with  his  eye 
from  uinl)ilicus  to  symphysis;  then  holding  the  skin  a  little  tense  on  either  side 
with  thumb  and  middle  finger,  he  cuts  with  one  sweep,  with  a  shar]),  broad- 
bellied  scalpel,  through  the  skin  and  subcutaneous  fat  down  to  the  deep  fascia 
covering  the  muscle.  The  linea  alba  is  at  once  seen  as  a  distinct  white  line,  or 
is  felt  as  a  cord  between  the  recti ;  if  not  found  in  this  way  it  may  be  exposed 
by  making  a  slightly  oblique  incision  through  the  fascia  from  above  downward, 
crossing  its  course.  With  the  linea  as  a  guide,  the  incision  is  continued  in  be- 
tween the  recti  muscles.  It  does  no  harm  if  in  the  search  the  sheath  is  opened 
and  the  muscle  exposed  ;  when  this  occurs,  the  linea  is  found  on  that  side  which 
yields  least  upon  making  gentle  traction  on  the  fascia. 

The  operator  and  his  assistant  now  catch  the  underlying  fat  and  connective 
tissue  (subperitoneal  fat)  with  a  pair  of  rat-toothed  forceps  on  either  side,  a 
little  distance  apart,  and  lift  it  up ;  it  is  then  incised  and  the  delicate  j^eri- 
toncum  below  picked  up  in  like  mnnner.     Immediately  above  the  peritoneum 


14       PRINCIPLES    AND    COMPLICATIONS   COMMON    TO    ABDOMINAL   OPERATIONS. 

two  veins  running  vertically  are  usually  found  close  to  the  median  line,  2  or 
3  millimeters  apart.  They  are  often  1  or  2  millimeters  in  diameter,  and  it  is 
advisable  not  to  cut  them  when  it  can  be  avoided.     (See  Fig.  19.) 

At  this  point,  beneath  the  muscles,  the  inexperienced  operator  may  become 
confused  and,  under  the  impression  that  he  is  gaining  access  to  the  abdominal 
cavity,  begin  to  dissect  outward  between  the  muscular  and  peritoneal  layers.  I 
have  seen  this  fruitless  and  embarrassing  quest  continued  for  twenty  minutes 
before  the  peritoneum  was  opened.  Indeed,  it  was  not  uncommon  for  the  older 
operators  to  consume  from  ten  minutes  to  half  an  hour  in  making  the  incision. 
This  error  is  to  be  avoided  by  picking  up  the  tissues  on  each  side  of  the  median 
line  as  described  and  incising  them  inward,  layer  by  layer,  always  keeping  in  the 
center.  The  j)eritoneum  must  be  picked  up  with  great  care  to  avoid  catching 
intestines  or  omentum  in  the  forceps ;  when  it  is  nicked  slightly,  air  rushes  in 
and  the  abdominal  wall  balloons  out  a  little,  while  the  intestines  fall  away. 
This  is  particularly  noticeable  when  the  pelvis  is  elevated.  The  opening  is  then 
enlarged  sufficiently  to  admit  the  index  finger,  which  is  swept  around  to  make 
sure  that  there  are  no  parietal,  intestinal,  or  omental  adhesions,  and  that  the 
bladder  is  not  close  to  the  incision.  With  this  assurance,  the  incision  in 
the  peritoneum  is  enlarged  to  the  full  size  of  the  cut  on 
the   skin    surface. 

Nothing  is  gained,  but  much  advantage  is  lost,  by  making  the  incision  fun- 
nel-shaped, long  on  the  skin  surface  and  short  on  the  peritoneum. 

Hemorrhage  from  the  incision  is  not  often  troublesome,  although  the  pre- 
liminary scrubbing  of  the  abdomen  may  dilate  the  capillaries  and  so  give  rise  to 
a  free  capillary  oozing  at  first ;  as  a  rule,  this  ceases  within  a  minute  or  so,  and 
may  be  disregarded. 

In  more  active  bleeding  a  few  artery  clamps  may  be  necessary  to  catch  the 
vessels,  which  are  then  tied  at  once  with  fine  catgut.  More  care  must  be  taken 
to  prevent  the  loss  of  even  a  small  amount  of  blood  in  this  way  if  the  patient  is 
weak  or  has  had  a  hemorrhage.  By  tying  all  the  actively  bleeding  vessels  in  the 
incision  at  once,  the  liability  to  the  formation  of  a  hematoma  and  subsequent 
suppuration  is  much  lessened. 

I  have  followed  this  plan  of  making  a  median  abdominal  incision  through 
the  linea  alba  in  over  two  thousand  celiotomies,  and  have  no  reason  to  distrust  it 
on  the  ground  advocated  by  some  surgeons  that  the  cicatricial  union  is  less  firm 
and  secure  than  in  those  cases  where  the  incision  is  made  lateral  to  the  median 
line. 

Exposure  of  the  Field  of  Operation. — E  levation  of  the  Pelvi  s — A  d  - 
vantages  and  Disadvantages . — One  of  the  most  important  maneuvers 
in  abdominal  surgery  is  the  elevation  of  the  pelvis  so  as  to  displace  the  obtrud- 
ing loops  of  intestines  lying  between  the  incision  and  the  pelvic  viscera ;  by 
doing  this,  the  field  of  operation  is  perfectly  exposed  to  sight  and  touch.  This 
is  especially  necessary  when  numerous  adhesions  and  extensive  bleeding  areas 
are  to  be  dealt  with,  for  the  work  proceeds  more  rapidly  and  with  greater  cer- 
tainty than  without  the  elevation. 


EXPOSURE    OF   THE   FIELD    OF    OPERATIOX.  15 

The  advantages  of  this  posture  were  first  appreciated  by  Bardenheuer,  of 
Cologne,  as  noted  by  Dr.  E.  Gushing  [see  Die  Drainirung  der  Peritoaealhohle, 
Stuttgart,  1881,  p.  276). 

Before  the  elevated  posture  came  into  general  use  much  dexterity  was  ac- 
quired in  manipulating  the  intestines,  to  keep  them  out  of  the  field,  with  fingers 
and  sponges  ;  this  is  now  unnecessary,  because  the  simple  position  mechanically 
throws  all  the  movable  viscera  up  toward  the  diaphragm  and  out  of  the  way. 

In  the  elevated  posture  the  patient  lies  upon  her  back  on  an  inclined  plane, 
with  the  pehds  raised  more  or  less  above  the  level  of  the  chest.  To  secure 
this  elevation  in  a  simple  manner,  a  variety  of  tables,  and  attachments  for  tables 
already  in  use,  have  been  devised.  These  differ  in  general  in  two  ways,  one  pro- 
viding for  the  tilting  of  the  whole  body,  the  other  flexing  the  back  while  the 
shoulders  and  head  lie  flat.  A  number  of  these  tables  admirably  fulfill  the 
various  recpiirements  :  such  are  the  Edebohls,  Cleveland,  and  Boldt  tables.  My 
own  table  is  provided  with  a  simjjle  rest  for  the  abdomen  and  hips,  which  is  ele- 
vated and  held  in  position  by  means  of  a  ratchet  attachment  (see  Chapter  I). 

The  advantages  of  the  elevated  posture  are  so  great  that  it  is  indispensable  in 
all  pelvic  and  lower  abdominal  work  ;  the  parts  to  be  operated  upon  are  per- 
fectly exposed  to  view  as  well  as  touch,  giving  the  operator  a  clear  knowledge 
of  the  condition  of  the  structures  throughout  the  operation.  One  of  the  most 
important  advantages  is  the  fact  that  the  intestines  are  kept  out  of  the  way 
without  handling  them ;  moreover,  by  causing  the  blood  to  gravitate  toward 
the  head  the  danger  of  shock  is  diminished,  especially  in  anemic  women.  I 
consider  it  also  an  important  advantage  that  the  operator  looks  into  the  pelvis, 
and  handles  the  pelvic  structures  without  the  necessity  of  bringing  his  own  and 
his  assistant's  head  directly  over  the  incision. 

The  amount  of  elevation  needed  will  vary  with  each  case.  In 
stout  women,  where  there  is  a  redundance  of  fat  within  the  abdomen,  it  may 
be  necessary  to  1-aise  the  body  to  an  angle  of  45°.  As  a  rule,  an  elevation  of 
from  18°  to  30°  will  be  suflicicnt.  When  the  patient  becomes  deeply  cyan- 
osed  and  the  breathing  stertorous,  she  must  be  let  down  lower.  The  ob- 
servant operator  will  discover,  after  the  intestines  have  once  gravitated  toward 
the  diaphi-agm  well  out  of  the  way,  that  he  may  then  let  the  pelvis  down  much 
lower,  often  quite  near  the  table,  and  continue  his  operation  without  embarrass- 
ment from  obtruding  bowels.  I  would  say,  as  a  general  rule,  that  it  is  best  to 
begin  with  a  high  elevation,  40°  to  30°,  and  then  to  continue  the  ojieration  at  a 
lower  elevation.  By  elevating  the  patient  for  one  or  two  minutes  just  before 
beginning  the  operation,  on  opening  the  abdomen  the  bowels  will  then  be  found 
already  well  out  of  the  way. 

In  order  not  to  waste  time  waiting  for  the  intestines  to  gravitate  slowly  into 
the  upper  abdomen,  and  to  dispose  of  obtruding  coils,  it  is  a  great  help  to  use 
n  on -absorbent  cotton  pads  covered  with  gauze  to  push  them  out  of 
the  way  and  hold  them  there.  I  always  have  at  hand  for  this  purpose  a  num- 
ber of  little  bolsters,  al)out  12  centimeters  (5  inches)  long  and  4  to  6  centimeters 
(2^  inches)  in  diameter,  made  of  non-absorbent  cotton  enclosed  in  gauze  and  ster- 


16       PRINCIPLES   AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 

ilized.  The  non-absorbent  cotton  retains  its  form  and  elasticity,  and  is  there- 
fore better  than  absorbent  cotton. 

The  dangers  of  the  elevated  position  are  four:  First,  i t 
may  be  the  means  of  carrying  septic  matter  from  the 
pelvis  into  the  upper  abdomen.  This  will  be  avoided  by  packing 
in  gauze  and  sponges  so  as  to  wall  oif  the  pelvis  from  the  abdominal  cavity  in 
all  inflammatory  cases  where  pus  is  found.  If  the  operator  expects  to  open  a 
pelvic  abscess,  he  must  let  the  patient  down  ahnost  level  and  do  it  in  that  posi- 
tion. In  case  of  an  unexpected  rupture  of  an  abscess,  or  the  discovery  of  free 
pus  in  the  pelvis  on  oj^ening  the  abdomen,  the  patient  must  be  dropped  at  once 
to  a  level  position,  and  sponges  and  gauze  packed  rapidly  in  to  catch  the  dis- 
charge. If  the  pus  has  become  widely  distributed,  it  is  better  to  irrigate  the 
lower  abdomen  freely  at  once  and  then  to  pack  in  sponges  and  gauze  while  con- 
cluding the  operation,  after  which  it  is  best  to  irrigate  thoroughly  once  more. 

Secondly,  the  elevated  posture  tends  to  check  bleeding 
from  vessels,  which  may  become  active  enough  to  destroy  life  when  the 
horizontal  posture  is  resumed.  This  must  always  be  borne  in  mind,  and  will 
only  be  avoided  by  taking  unusual  care  to  stop  all  bleeding,  and  then  by  exam- 
ining the  whole  field  some  time  after  letting  the  pelvis  down,  to  see  if  there  is 
any  flow. 

Thirdly,  a  perforated  omentum  may  cause  death  by  catch- 
ing and  retaining  a  loop  of  intestine  in  one  of  its  holes,  and  so 
causing  an  ileus.  I  lost  one  case  in  this  way.  Although  the  abdomen  was  opened 
again  and  some  adhesions  broken  up  and  the  distended  bowel  relieved,  the  incar- 
cerated loop  was  first  discovered  at  the  post-mortem  examination. 

Fourthly,  a  stout  woman  may  lose  her  life  in  the  struggle 
to  keep  her  diaphragm  going  against  the  great  weight  of  fat  viscera 
pressing  upon  it.  The  danger  signs  are  rapid  stertorous  breathing,  deep  cyano- 
sis, irregular  pulse,  dilated  pupils,  and  cessation  of  cardiac  pulsation  from  an 
overdistended  right  heart. 

Retractors . — Flat  and  scoop-shaped  retractors  of  three  sizes  are  necessary 
to  hold  apart  the  edges  of  the  abdominal  incision,  converting  the  linear  ojjening 
into  an  oval  which  gives  a  perfect  view  of  the  parts  beneath.  After  a  thorough 
exposure  and  study  of  the  field  to  determine  the  exact  character  of  the  opera- 
tion, one  of  the  retractors  is  removed,  and  the  assistant  then  follows  the  surgeon 
as  he  proceeds  with  the  enucleation  and  suturing  by  retracting,  first  one  side, 
then  the  lower  angle,  and  then  the  opposite  side,  as  the  operation  progresses. 
One  of  the  most  important  uses  of  the  retractors  is  to  avoid  the  constant  con- 
tact of  the  hands  with  the  abdominal  incision,  increasing  the  liability  to  in- 
fection. 

Where  much  force  has  been  necessary  to  hold  the  incision  open,  its  edges  are 
always  bruised  and  infiltrated  with  blood.  Cases  which  have  come  to  the  post- 
mortem table  have  invariably  shown  widespread  ecchymoses  on  both  sides  ex- 
tending out  under  the  peritoneum.  This  will  be  in  some  measure  j^revented  by 
making  a  longer  incision,  not  so  hard  to  hold  open,  and  by  gentleness  in 


METHODS    OF    DEALING    WITH    ADHESION'S.  17 

retracting.  The  use  of  the  hand  as  a  retractor,  protected  by  gauze,  is  an  ad- 
vantage in  this  respect. 

Dr.  W.  E,  Ashton  has  devised  an  excellent  self -retaining  bivalve  retractor 
for  use  in  incisions  of  medium  size. 

The  Illumination  of  the  Field. — The  illumination  of  the  field  of 
operation  is  best  obtained  through  a  high  window  admitting  north  light.  If  this 
can  not  be  obtained,  a  diiiuse  light  from  a  number  of  windows  in  a  room 
whose  walls  are  painted  of  a  light  color  is  good.  But  a  dull,  cloudy  day  may  so 
obscure  the  light  in  the  best-appointed  operating  room  that  artificial  means  of 
illumination  should  always  be  at  hand.  Indeed,  I  constantly  resort  to  artificial 
light  even  under  ordinary  circumstances.  An  electric  light  of  sixteen  or  twenty 
candle  power  supplied  from  a  street  current  is  the  most  satisfactory  form  of 
illumination.  The  burner  is  attached  to  a  short  handle  and  connected  by  long 
insulated  wires  to  the  socket  on  the  wall.  A  good  tin  reflector,  painted  black  on 
the  outside  and  with  white  enamel  paint  on  the  inside,  encloses  one  half  of  the 
lamp  and  protects  the  operator's  eyes  during  the  illumination  of  the  abdomen. 
The  assistant  holds  the  light  and  directs  it  where  it  is  wanted,  taking  care  to 
keep  it  far  enough  away  from  the  wound  not  to  interfere  with  the  operation. 
After  a  little  experience  the  operator  will  find  no  difficulty  in  looking  in  beside 
the  light,  and  so  gaining  a  perfect  view  of  all  parts  of  the  pelvis,  at  the  same  time 
using  instruments  and  sponges  and  passing  ligatures  freely  without  striking  the 
lamp,  which  should  be  held  about  six  inches  above  the  incision.  Where  the 
electric  current  from  the  street  is  not  available  a  storage  battery  can  be  util- 
ized. The  inconveniences  of  a  storage  battery  are  its  weight  and  the  uncer- 
tainty of  the  light,  which  may  suddenly  give  out  when  most  wanted.  The 
latter  objection,  however,  has  been  largely  overcome  by  improved  construction, 
and  I  find  a  storage  battery  a  necessary  and  valuable  adjuvant  in  my  private 
work.  The  weight  of  a  battery  which  is  not  too  large  to  carry  around  is 
about  twenty  pounds,  and  it  measures  8  by  9  by  10  inches  ;  its  working  time  is 
about  fifteen  hours,  after  which  it  nuist  be  refilled.  This  may  be  done  from 
any  direct  (Edison)  street  current  by  interposing  a  Vetter  current  adapter,  which 
fits  into  the  ordinary  lamp  socket  and  carries  a  lamp  for  the  necessary  resist- 
ance between  the  source  of  current  supply  and  the  battery.  The  head  light 
which  goes  with  the  storage  battery  is  a  miniature  lamp  of  four  candle  power, 
enclosed  in  a  cylinder  with  a  refiector  behind  and  a  plano-convex  lens  in  front 
of  it ;  it  has  a  ratchet  for  adjustment,  and  is  attached  to  a  flexible  steel  head- 
band with  cords  to  connect  it  to  the  battery.  A  battery  a  little  larger  than 
this  is  capable  of  running  a  hand  light  of  six-candle  power  for  some  hours. 

In  operations  conducted  in  ]irivatc  houses  a  common  candle  held  in  a  metal 
tube  with  a  conical  tin  reflector  will  do  in  case  of  urgent  need.  The  light  from 
a  lamp  may  even  be  thrown  into  the  pelvic  cavity  with  a  common  hand  mirror 
in  extreme  necessity. 

Methods  of  Dealing  with  Adhesions. — Operations  upon  pelvic  tumors  and  in- 
flammatory masses  are  often  com  plicated  by  adhesions  to  the  pelvic  walls, 
pelvic  floor,  omentum,  uterus,  rectum,  small  intestines  and  colon,  bladder,  and 
43 


18       PRINCIPLES   AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 

vermiform  appendix.  Adhesions  to  the  pelvic  walls  and  floor  vary  greatly  in 
character,  sometimes  being  light  and  easily  broken,  at  other  times  dense,  so  as 
only  to  be  severed  by  sacrificing  a  portion  of  the  underlying  structure.  They 
can  usually  be  freed  by  carefully  distinguishing  a  plane  of  cleavage  between  the 
peritoneum  of  the  tumor  and  the  visceral  peritoneum,  and  following  this  cau- 
tiously with  the  fingers  as  the  tumor  is  stripped  off. 

Omental  Adhesions . — One  of  the  oflices  of  the  omentum  is  to  re- 
move foreign  materials  from  the  abdominal  cavity,  or  to  encapsulate  them,  and 
for  this  reason  it  is  found  with  extreme  frequency  adhering  to  inflammatory 
masses.  If  the  mass  is  small  the  omentum  may  envelop  it  completely ;  where 
the  whole  pelvis  is  choked,  it  often  acts  as  a  diaphragm  to  separate  the  pelvis 
from  the  abdominal  cavity  by  forming  adhesions  to  the  pelvic  brim  on  all  sides. 
In  other  cases  it  may  adhere  to  one  part  of  the  brim  or  to  the  uterus  or  bladder. 

The  pel\4c  inflammatory  diseases  are  most  likely  to  be  accompanied  by 
omental  adhesions.  In  a  series  of  one  hundred  hystero-salpingo-oophorectomies 
in  my  clinic  I  find  that  there  were  forty-seven  cases  (47  per  cent)  in  which  the 
omentum  was  adherent.  The  adhesions  varied  from  light  velamentous  ones, 
easily  separated,  to  dense  indurated  masses  covering  in  and  encapsulating  puru- 
lent collections.  In  five  of  these  cases  it  was  necessary  to  remove  large  portions 
of  the  omentum  attached  to  purulent  foci.  In  other  instances  adherent  portions 
of  the  omentum  were  simply  ligated  and  cut,  the  divided  portions  remaining 
attached  to  the  enucleated  structures.  Adhesions  to  the  anterior  abdominal 
wall  are  frequent,  especially  after  pelvic  operations. 

An  adherent  omentum  always  impedes  the  operator,  and  must  be  released 
at  the  outset,  either  by  stripping  off  light  adhesions  with  the  fingers,  or  by  ligat- 
ing  and  excising  a  sufiicient  portion  of  a  densely  adherent  omentum  to  leave  a 
clear  field  for  the  pelvic  operation.  The  removal  of  a  portion  or  all  of  the 
omentum  does  not  increase  the  danger  of  the  operation,  and  it  should  be 
promptly  resorted  to  rather  than  waste  much  time  in  separating  adhesions  and 
applying  numerous  ligatures  in  trying  to  save  the  omentum.  Cut  or  torn  omen- 
tal vessels  bleed  freely  and  persistently,  and  all  hemorrhages  from  this  source 
must  be  promptly  checked.  If  there  are  any  obscure  bleeding  j^oints  after  sepa- 
ration of  a  number  of  omental  adhesions,  they  can  be  located  by  drawing  the 
omentum  out  of  the  incision  and  spreading  it  out  on  clean  white  gauze  ;  the  red 
stains  found  on  the  gauze  after  a  few  minutes  then  correspond  to  bleeding  points. 
It  is  always  preferable  to  ligate  and  excise  persistently  oozing  sections  of  omen- 
tum rather  than  to  search  out  individual  vessels.  Areas  of  omentum  which  are 
densely  adherent  to  pelvic  structures  can  be  tied  off  with  fine  silk  or  catgut  liga- 
tures and  cut  just  below,  and  left  in  the  pelvis  with  safety.  A  rapid  way  of 
tying  off  the  omentum  is  to  push  a  finger  or  an  arteiy  forceps  through  one  of 
tlie  clear  spaces,  drawing  a  ligature  back,  tying  it  over  the  free  border,  and  cut- 
ting it  just  below.  By  continuing  this  across  the  abdomen,  the  whole  omentum 
can  be  tied  off  in  small  sections,  catching  several  vessels  with  each  ligature. 

Uterine  Adhesion  s. — In  all  pelvic  inflammatory  diseases  the  uterus 
is  usually  found  attached  to  the  adjacent  structures  by  its  lateral  or  posterior  sur- 


METHODS    OF    DEALING    WITH    ADHESIONS.  19 

faces.  These  adhesions  are  usually  peeled  off  without  difficulty  in  the  course  of 
the  operation,  and  only  demand  attention  if  oozing  is  persistent.  A  small 
quantity  of  dry  sterilized  powdered  subsulphate  of  iron  may  be  applied  on  the 
tip  of  the  finger  or  a  bit  of  gauze  with  excellent  styptic  effect  to  fine  bleeding 
points.  Sutures  may  be  passed  through  the  uterus  with  impunity  in  any  number 
and  at  any  depth,  so  long  as  they  do  not  include  the  mucosa.  If  the  oozing  area 
is  limited,  a  suture  threaded  directly  into  a  small  needle  may  be  passed  under 
the  bleeding  area  a  short  distance  from  it.  The  stitch-hole  thus  made  some- 
times bleeds  more  actively  than  the  points  which  it  is  designed  to  control,  but 
on  tying  the  suture  the  tissue  will  become  blanched  and  the  oozing  cease.  Care 
must  be  taken  not  to  tie  the  suture  too  tightly,  or  it  will  cut  and  the  hemorrhage 
be  made  worse.  This  accident  will  be  avoided  by  observing  the  surface,  as  the 
knot  is  tied,  and  ceasing  further  traction  as  soon  as  the  oozing  is  checked. 

Hemorrhage  from  longer  and  deeper  injuries  to  the  uterus  may  be  con- 
trolled by  a  series  of  interrupted  ligatures  passed  transversely  beneath  the 
wound.  Oozing  areas  on  the  lateral  surfaces  of  the  uterus  may  occasionally  be 
checked  by  drawing  a  part  of  the  broad  ligament  over  against  it  with  sutures. 
When  there  is  a  slight  persistent  oozing  over  a  wide  area  of  the  posterior  sur- 
face of  the  uterus,  which  can  not  be  conveniently  controlled  by  the  means  just 
described,  the  uterus  may  be  forced  down  into  retroposition  on  the  pelvic  floor 
without  suture.  I  have  found  this  method  effective  in  a  number  of  cases,  and 
have  seen  no  disadvantage  from  it. 

An  adherent  retroflexed  uterus  may  be  freed  by  simply  stripping  up  the 
fundus  with  the  fingers,  if  the  adhesions  are  light.  If  they  are  dense,  it  is 
better  to  expose  the  uterus  and  pull  the  fundus  forward,  putting  the  adhesions 
on  the  stretch  and  cutting  them  with  scissors  under  inspection.  If  the  uterus  is 
extensively  adherent,  it  is  better  to  remove  it  with  the  lateral  structures  (hystero- 
salpingo-oophorectomy). 

Rectal  Adhesions . — Hectal  adhesions  are  the  most  troublesome  as  a 
class,  because  they  are  often  situated  deep  down  in  the  pelvis,  so  as  to  be  almost 
inaccessible,  and  because  the  bowel  can  not  be  displaced  and  brought  up  into  the 
incision  or  outside,  as  with  adhesions  of  the  small  intestines.  In  the  one  hun- 
dred cases  of  pelvic  inflammatory  disease  referred  to  under  the  previous  head- 
ing, thirty-five  had  more  or  less  extensive  adhesions  between  the  inflamed 
structures  and  the  rectum.  These  adhesions  are  best  dealt  with  by  lifting 
the  uterus  or  adherent  tube  and  ovary  carefully  upward  and  forward  away 
from  the  bowel.  If  the  adhesion  is  stretched  a  little  by  this  maneuver,  so 
as  to  present  a  little  space  between  the  adhering  organs,  the  scissors  may 
l)e  used  with  good  effect  to  separate  them.  Often  in  this  way  a  widely  ad- 
herent area  may  be  released  without  injury  to  the  bowel.  Where  the  adhesion 
is  flat  and  the  adherent  mass  can  not  be  raised  up  from  the  bowel,  the  fingers 
may  be  tried  judiciously,  and  an  effort  made  to  strip  off  the  adhesion  by  working 
the  fingers  in  the  direction  of  least  resistance,  but  always  keejnng  the  palmar 
surfaces  toward  the  tumor  or  the  uterus,  lifting  it  oft"  the  bowel.  A  plane 
of  cleavage  is  almost  always  found  between  thfe  old  agglutinated  peritoneal  sur- 


20       PRINCIPLES   AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 


faces,  and  no  injury  is  sustained  in  tlie  separation.  If  tliis  plan  does  not  succeed 
it  is  better  to  leave  beliind  a  piece  of  a  tumor,  or  the 
outer  wall  of  an  abscess  sac,  where  the  adhesion  is  so 
dense  that  it  can  not  be  separated  without  imminent  risk 
of  opening  the  lumen  of  the  bowel.  Such  a  piece  can  afterward 
be  trimmed  down  and  its  lining  membrane  peeled,  scraped,  or  burned  off. 

"When  any  or  all  of  the  coats  of  the  bowel  are  torn,  the  edges  of  the  tear 
must  be  neatly  approximated  by  sutures.  This  is  usually  easy  on  account  of  the 
thickness  of  its  coats,  which  give  the  suture  a  good  hold.     The  chief  difficulty 

in  suturing  often  arises  from  the  brittle- 
ness  of  the  tissue  which  is  infiltrated 
with  inflannnatory  products,  causing  the 
suture  to  tear  out  Avhen  the  attempt  is 
made  to  tie  it.  If  a  hold  can  be  secured, 
interrupted  mattress  sutures  or  simple  in- 
terrupted sutures  of  fine  silk  are  applied 
and  tied  at  frequent  intervals.  When 
the  torn  area  is  a  large  one,  I  have  suc- 
ceeded in  a  number  of  instances  in  pro- 
tecting it  by  laying  the  uterus  down  on 
it  in  retroposition  so  that  the  posterior 
surface  of  the  uterus  made  good  the  de- 
fect. In  one  case,  a  negress  (J.  S.,  332), 
operated  upon  Sept.  2,  1890,  there  was  a 
long,  triangular  tear  through  the  muscu- 
lar coats  of  the  rectum,  with  its  apex  just 
below  the  promontory  of  the  sacrum.  I 
closed  it  by  suturing  the  posterior  surface  of  the  uterus  to  the  bowel  with  two 
continuous  sutures,  beginning  at  the  pelvic  floor  on  either  side  and  extending 
up  to  the  apex.  This  patient  made  an  excellent  recovery  without  any  rectal  dis- 
turbance {Johns  Hopkins  Hospital  Report  in  Gynecology^  vol.  ii,  p.  413). 

When  the  bowel  has  been  widely  opened,  or  when  the  suturing  has  been 
unsatisfactory,  it  is  always  wiser  to  put  a  gauze  drain  in  the  pelvis  through  the 
vaginal  vault  to  provide  for  a  possible  infection  through  the  injured  bowel. 

It  is  better  to  move  the  bowels  on  the  third  day  with  a  pill.  The  nurse  must 
be  cautioned  under  no  circumstances  to  give  a  large  enema,  distending  the 
bowel.  At  the  utmost  nothing  more  than  a  little  glycerin  and  oil  should  be  in- 
jected into  the  rectum  through  a  syringe  with  a  short  nozzle. 

Other  Intestinal  Adhesions. — Intestinal  adhesions  of  all  kinds 
must  be  handled  with  extreme  care,  to  avoid  wounding  the  coats  of  the  bowel 
and  so  making  an  avenue  for  septic  invasion  of  the  peritoneal  cavity. 

In  general  there  are  two  varieties  of  these  adhesions — the  loose  membranous 
or  V  e  1  a  m  e  n  t  o  u  s ,  and  those  which  are  dense  and  organize  d — involv- 
ing one  or  more  of  the  coats  of  the  intestines.  In  order  to  avoid  the  danger 
of  blindly  tearing  a  hole  in  the  intestines,  intestinal  adhesions  should  invariably 


Fig.  316.— Stricture  of  the  Kectum  due  to  Pel- 
vic Inflammatory  Disease,  seen  throucih 
THE  Proctoscope,  9.5  Centimeters  above 
THE  Anus.     Dec.  8,  1896.     Natural  Size. 


METHODS   OF    DEALIXG    AVITH    ADHESIONS. 


21 


be  broken  ujd  under  direct  inspection.  Yelamentous  membranous  adhesions  are 
readily  stripped  off  without  involving  the  integrity  of  the  bowel,  and,  on  account 
of  their  low  organization  and  poor  vascularization,  they  do  not  give  rise  to  hem- 
orrhage. They  prove  most  difficult  to  handle  if  they  are  bunched  together,  when 
they  acquire  strength,  like  a  string  of  spider's  web.  This  must  be  avoided  by 
spreading  them  out  and  dealing  with  them  separately. 

The  case  is  different  with  dense  flat  adhesions,  where  the  plastic  lymph  has 
undergone  organization,  and  the  peritoneal  surfaces  are  bound  intimately  to- 
gether by  the  newly  formed  connective  tissue,  richly  supplied  with  blood  vessels. 
This  class  of  adhesions  is  most  frequently  associated  with  pelvic  abscess.  On 
attempting  to  strip  the  adjacent  loops  of  intestines  loose,  the  peritoneal  coat  is 
torn,  and  sometimes  the  external  and  internal  muscular  coats  are  ruptured  with 
it,  even  into  the  lumen  of  the  bowel,  and  if  much  force  is  used,  the  tear  will 
often  extend  far  beyond  the  point  at  which  it  started.  To  prevent  this  the  whole 
area  must  be  well  exposed  and  the  adherent  structures  released  slowly  and  gently 
by  dissection,  as  far  as  possible  mth 
the  fingers,  using  the  point  of  the 
knife  or  scissors  only  when  neces- 
sary to  nick  strong  bands. 

Adhesions  to  benign  tumors 
and  cysts  and  to  the  uterus  are 
more  easily  dealt  with,  inasmuch 
as  a  portion  of  the  wall  of  the  cyst, 
or  a  part  of  a  tumor,  or  a  piece 
of  the  uterine  wall  may  be  cut  off 
with  impunity  and  left  attached  to 
the  bowel  to  avoid  opening  it.  If 
there  is  oozing  from  this  surface 
or  from  the  intestine,  it  may  be 
checked  either  by  cauterizing  it 
lightly  or  by  bringing  together  its 
free  edges  with  sutures. 

In  one  hundred  cases  of  pel- 
vic inflammatory  disease  in  which 
hystero-salpingo-oophorectomy  was 
performed  the  intestines  were  ad- 
herent either  to  the  inflammatory 
structures  or  among  themselves  in 
fifty-two  cases. 

In  twenty-four  cases  the  intestine  was  injured  in  tlie  enucleation,  varying  in 
degree  from  a  simple  laceration  of  the  external  coat  to  complete  nipture  of  all 
the  coats. 

Appendical  Adhesions, — A  large  percentage  of  pelvic  inflamma- 
tory diseases  and  ovarian  tumors  are  associated  with  adhesions  to  the  vermiform 
appendix,  which  is  quite  often  found  firmly  attached  to  the  mass  by  its  extrem- 


Fio.  317. — Vekmikoum  Aitexdix  (A/>/>.)  ahiikrent  to 
A  Large  Papillahv  Ovakian'  Cyst.  Dec.  "22,  1894. 
*/6  Nattual  Size. 


22       PEINCIPLES    AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 

ity  or  its  lateral  wall.  The  cases  in  which  the  vermiform  appendix  is  most 
likelj  to  be  involved  are  those  in  which  its  free  end  hangs  down  over  the  pelvic 
brim  close  to,  or  in  contact  with,  an  inHamed  right  tube.  An  inHammatorj 
affection  of  the  tube  will  in  this  way  easily  involve  the  appendix,  and  an  appen- 
dicitis will,  on  the  other  liand,  infect  the  tube ;  so  that  the  appendicitis  may  be 
either  primary  or  secondary,  and  the  same  may  be  said  of  the  salpingitis.  When 
the  appendicitis  is  secondary  it  is  usually  limited  to  the  outer  coats. 

In  one  of  my  cases  in  which  the  disease  was  primarily  in  the  a^^pendix  this 
organ  was  perforated,  the  pelvis  was  filled  with  pus,  and  the  tube  became  in- 
flamed and  the  ovary  gangrenous,  appearing  green  and  black.     The  patient  sur- 


FiQ.  318.— Extensive  Pelvic  Inflammatory  Disease  with  Genekal  Adhesions,  due  to  TuBERcrLAji 
Endometritis,  Pelvic  Peritonitis,  Tuberculosis  of  both  Tubes  and  of  Eight  Ovary. 

The  right  ovary  is  5  x  4  x  3  centiiiieters  in  size,  and  is  filled  with  pus.    The  drawing  is  CMieeially  intended 
to  show  the  densely  adherent  vermiform  appendix.     Path.  No.  1071.     Op.  Feb.  15,  1896.     ISatural  size. 

vived  the  operation  for  the  removal  of  these  structures,  and  was  up  and  going 
about  when  she  died  suddenly  on  the  twenty-eighth  day,  suffocated  by  a  large 
peri-hepatic  abscess  rupturing  into  a  bronchus. 

Gentle  traction  will  sometimes  suffice  to  free  an  adherent  appendix,  but  it 
must  be  watched  for  a  time  to  make  sure  that  it  will  not  continue  to  bleed  if  it 
is  dropped  without  being  removed.  Sometimes  a  fine  silk  suture  at  the  bleed- 
ing point  will  check  the  flow,  but  this  is  often  not  admissible,  because  the  appen- 
dix tends  to  tear  and  bleed  more  freely  after  the  puncture  of  a  needle.  If  the 
hemorrhage  persists,  amputation  of  the  appendix  is  best. 

Where  the  adhesions  are  firm  it  is  b etter  not  to  try  to 
save  the  appendix,  but  to  remove  it  with  the  right  tube 
and  ovary   (see  Chap.  XXXVI). 


IXJUKIES   TO    THE    BLADDER   AXD    URETERS.  23 

Vesical  Adhesions . — The  bladder  occupies  a  comparatively  isolated 
position  in  the  antei'ior  part  of  the  pelvis,  and  for  this  reason  vesical  adhesions 
are  rarer  than  adhesions  elsewhere.  The  omentum  is  the  abdominal  organ  most 
liable  to  contract  adhesions  with  the  bladder.  In  almost  all  cases  the  vesical 
attachments  are  to  the  posterior  pelvic  viscer a — that  is,  to  the 
uterus,  rectum,  ovaries,  and  tubes.  Sometimes  but  a  few  strong  bands  connect 
the  bladder  with  one  of  the  organs  behind  it,  at  others  a  large  j^art  of  the  vanlt 
of  the  bladder  is  drawn  over  the  top  of  the  uterus  and  its  lateral  structures  by 
the  adhesions  to  the  rectum,  completely  burying  them  out  of  sight.  In  order 
not  to  injure  the  vascular  walls  of  the  bladder,  delicate  manipulation  is  required 
to  separate  it  from  the  adjacent  adherent  structures.  Adhesions  may  usually  be 
severed  with  knife  or  scissors,  leaving  behind,  if  necessary,  a  part  of  the  uterus 
or  the  wall  of  a  tumor.  All  vesical  tears  should  be  repaired  at  once  by  suture. 
If  the  peritoneal  coat  alone  is  injured  the  rent  may  be  approximated  by  a  con- 
tinuous suture.  A  deep  tear  opening  the  cavity  of  the  bladder  is  best  remedied 
by  a  series  of  interrupted  fine  silk  sutures  placed  close  together,  each  one  enter- 
ing on  the  peritoneal  surface  and  penetrating  deeply  enough  to  include  the  mus- 
cular coats,  but  not  the  mucous  coat.  When  these  sutures  are  tied  there  ought 
to  be  a  perfect  approximation,  which  of  itself  checks  all  hemorrhage.  If  the 
union  is  neat  no  fear  need  be  entertained  of  a  leakage  of  urine.  For  this 
reason  abdominal  drainage  'svill  not  be  necessary.  Urine  escaping  over  the  peri- 
toneum during  an  operation  is  not  harmful,  if  it  does  not  contain  septic  matter, 
as  in  cystitis.  In  this  case  too  great  care  can  not  be  taken  to  avoid  any  con- 
contamination  however  slight. 

Injuries  to  the  Bladder  and  Ureters. — Injuries  to  the  bladder  in  the  course  of 
an  al)d()minal  operation  arise  from  its  displacement  either  out  of  the  pelvis  be- 
neath the  abdominal  wall  in  front  of  the  peritoneum,  or  from  its  being  lifted 
up  into  the  abdomen  by  a  subi^eritoneal  tumor.  Such  accidents  most  commonly 
occur  in  the  case  of  large  fibroid  tumors  choking  the  pelvis  and  leaving  no  room 
for  the  expansion  of  the  bladder,  which  is  then  forced  to  distend  up  under  the 
cellular  tissue  of  the  abdominal  wall.  For  this  reason  it  is  important  in  all  oper- 
ations foi*  lai'ge  myomata  to  make  the  incision  slowly  and  with  great  care,  and  to 
cut  through  into  the  peritoneum  preferably  high  up  toward  the  umbilicus,  so  as 
to  keep  above  the  bladder,  and  then  to  continue  the  incision  downward,  guided 
by  a  finger  within  the  peritoneum. 

I  had  a  case  a  numl)er  of  years  ago  of  a  su]>purating  ovarian  cyst  which  had 
contracted  adhesions  with  the  bladder  and  dra<j<2:ed  it  halfwav  ui)  to  the  uinl)ili- 
cus.  In  opening  the  abdomen  I  unwittingly  cut  directly  through  the  bladder, 
whose  walls  were  greatly  thickened  by  inflammation.  The  result  of  this  acci- 
dent was  a  permanent  urinary  fistula.  The  bladder  is  often  lifted  up  into  the 
abdomen  by  large  fibroid  tumors,  and  will  inevitably  be  injured  in  the  process 
of  enucleation  if  two  rules  are  not  observed. 

1.  The  point  of  reflection  of  the  bladder  onto  the  uterus  nnist  be  found  by 
making  traction  on  the  vesical  peritoneum,  which  is  loose  and  movable,  and 
by  noting  the  line  of  firm  attachment  to  the  uterus. 


2i       PRINCIPLES    AND    COMPLICATIONS    COMMON    TO    ABDOMINAL    OPERATIONS. 

2.  The  anterior  incision  in  removing  the  uterus  must  always  be  made  from 
round  hgament  across  to  round  ligament,  following  this  line. 

By  neglecting  this  last  rule  in  extirpating  a  large  subperitoneal  fibroid  I  cut 
off  with  the  tumor  a  piece  of  the  bladder  as  large  as  the  palm  of  my  hand.  The 
hole  was  at  once  closed  with  interrupted  sutures,  and  healed  without  leaving  a 
fistula. 

The  ureter  is  often  laid  bare  from  the  broad  ligament  to  the  pelvic  brim  by 
the  removal  of  a  subperitoneal  fibroid  tumor.  ]No  ill  consequence  follows  the 
simple  exposure. 

There  is  great  danger  of  tying  or  piercing  a  ureter  in  the  effort  to  check 
hemorrhage  following  the  removal  of  an  adherent  mass  from  the  pelvic  floor. 
On  this  account  I  am  extremely  cautious  about  using  a  needle  and  suture  in  this 
situation.  I  once  pierced  a  ureter  in  such  a  case,  and  the  patient  had  a  drib- 
bling of  urine  from  the  incision  lasting  several  weeks,  when  it  ceased  sponta- 
neously. 

The  ureter  is  often  tied  in  removing  fibroids  or  fibrocystic  or  cancerous 
uteri,  and  the  only  safe  rule  to  avoid  such  an  accident  is  to  ti'ace  out  the  ureter 
from  pelvic  brim  to  vesical  ending,  making  sure  of  its  integrity.  It  may  be 
accidentally  cut  when  lifted  high  out  of  the  pelvis  on  a  subperitoneal  fibroid. 
The  only  way  to  avoid  this  is  to  examine  with  minute  care  before  tying  and  cut- 
ting any  distended  vessel  found  running  up  over  the  anterior  face  of  the  tumor 
looking  like  a  vein  or  lymphatic,  1  or  2  centimeters  in  diameter  (see  Chapter 
XXXI).  If  divided,  a  uretero-ureteral  anastomosis  must  be  performed  (see 
Chapter  XIII,  p.  466). 

Ligation  of  the  Pedicle. — Silk  is  the  best  ligature  material  for  the  pedicle  of  a 
pelvic  tumor,  and  if  not  weakened  by  the  sterilization  the  intermediate  size  (see 
Fig.  7)  will  be  strong  enough  and  less  liable  to  lodge  septic  matter  and  produce 
an  abdominal  fistula. 

AYhere  tissue  is  ligated  en  masse,  it  is  best  always,  as  an  additional  precau- 
tion, to  pick  up  the  exposed  mouths  of  the  large  vessels  separately  and  pull 
them  out  a  little  and  throw  an  additional  fine  suture  al)0ut  them.  By  this 
l^lan  hemorrhage  will  be  avoided,  even  if  the  pedicle  shrinks.  If  the  pedicle  is 
long  and  thin,  a  single  ligature  may  suffice  to  control  it.  It  is  then  cut  off  about 
2  centimeters  beyond  the  ligature.  A  thicker  pedicle  must  be  transfixed  by  two 
ligatures  and  tied  on  opposite  sides.  It  is  never  safe  to  tie  off  sessile  tumors  or 
tumors  with  short  pedicles  in  this  way,  on  account  of  the  extreme  danger  of 
the  slipping  of  the  ligatures. 

In  tying  oft'  ovarian  and  tul)al  tumors  I  have  long  since  abandoned  tne  plan 
of  pulling  the  mass  up  through  the  incision  and  transfixing  the  l)road  ligament 
with  two  ligatures  below  and  tying  in  opposite  directions.  There  can  be  no 
doubt  that  this  time-honored  tie  is  responsible  for  almost  all  the  hemorrhages 
occurring  after  simple  salpingo-oophorectomy.  I  have  not  found  the  Stafford- 
shire knot  one  whit  more  satisfactory,  knowing  of  many  cases  of  hemorj'hage 
following  its  use,  one  of  which  I  saw  in  the  hands  of  its  first  advocate. 

The  best  and  safest  way  to  tie  off  the  top  of  the  broad  ligament  is  to  tie  the 


By 

both 

index 

show 

eels  arc  secured 


LIGATION    OF   THE    PEDICLE. 


25 


ovarian  and  uterine  vessels  separately,  leaving  the  membranous  interval  free,  and 
without  attempting  to  draw  them  together.  When  the  structures  are  removed 
this  leaves  two  little  bunches  of  tissue  liolding  the  vessels,  one  at  the  pelvic 
brim  under  the  cecum  or  under  the  sigmoid  flexure,  and  the  other  at  the  uterine 
cornu ;  between  these  the  peritoneal  layers  of  the  broad  ligament  fall  together 
in  a  narrow  line. 

The  ovarian  vessels  are  easily  found  and  tied  by  transfixing  an  interval  at  the 
outer  extremity  of  the  broad  ligament  which  is  free  from  vessels,  and  then  tying 
over  the  top  of  the  broad  ligament  near  the  brim  of  the  pelvis ;  in  this  way  all 
the  veins  and  the  artery  are  included.  I  have  called  this  interval  "  the  clear 
space."     The  clear  space  is  formed  by  gathering  up  the  broad  ligament  between 


Fig.  320. — Encysted  SSii.k  LuiATiRE  in  the  Right  Bko.\i)  Ligament. 

The  ligature  liud  been  put  in  si.\  months  previously  to  li-rate  the  liir<:e  varicose  veiu.s  in  the  li<j:ameiit. 
The  left-hand  ti.'ure  sliows  the  relations  of  tlie  liiraturc.     No.  ioL     Natural  size. 


the  thumb  and  forefinger,  with  the  thumb  in  front,  just  beyond  the  fimbriated 
end  of  the  tube  and  behind  the  round  ligament  at  the  pelvic  brim.  As  the  broad 
ligament  is  lifted  the  vessels  are  raised,  and  if  a  lii^ht  is  held  behind,  the  translu- 
cent  tissues  are  seen  to  be  made  up  of  two  layers  of  peritoneum  and  entirely 
free  from  any  vessels.  So  thin  is  this  clear  space  that  if  it  is  held  a  little  tense, 
the  needle  often  punctures  it  with  a  click,  as  if  it  was  going  through  parchment. 
The  fine  silk  ligatures  used  in  ligatingthe  pedicles  become  encysted  in  lynij)h 
and  remain  innocuous.  Fig.  .SHO  shows  one  of  them  as  it  was  found  six  months 
after  its  introduction  for  the  purpose  of  ligating  the  enormously  tiilated  ovarian 
veins. ^  The  knotted  portion  of  the  ligature  remains  unchanged,  but  the  loop,  if 
it  is  a  long  one,  is  often  dissected  ai)art  into  its  ultimate  fibrils  by  the  leucocytes, 
when  the  silk  is  not  absorbed,  as  it  can  always  be  found  with  a  microscope. 


26       PRIXCIPLES   AXD    COMPLICATIONS    COMMON   TO    ABDOMINAL    OPERATIONS. 

Hemorrhage. — ^ Active  persistent  hemorrhage  is  perhaps  the  commonest  com- 
phcation  in  abdominal  surgery.  The  usual  source  of  bleeding  is,  first,  the  vessels 
in  the  al>dominal  incision  ;  second,  the  uterine  vein  and  arteries  ;  third,  the  ova- 
rian veins  and  arteries  ;  and  fourth,  the  vessels  of  adherent  structures,  such  as 
uterus,  pelvic  walls  and  floor,  broad  ligaments,  rectum,  small  intestines,  vermi- 
form appendix,  and  omentum. 

To  avoid  hemorrhage  as  far  as  possible,  the  surgeon 
must  tie  every  actively  bleeding  vessel  in  the  abdomen 
as  soon  as  it  is  severed.  When  the  hemorrhage  comes  from  the  ab- 
dominal walls  it  is  usually  enough  to  clamp  the  smaller  vessels  temporarily,  and 
upon  remo\ang  the  forceps  later  in  the  operation,  when  they  are  in  the  way,  the 
bleeding  will  have  ceased.  Occasionally  it  will  happen  that  the  source  of  blood 
accumulating  on  the  floor  of  the  pelvis  will  actually  be  found  in  a  small  vessel 
in  the  lower  angle  of  the  incision,  from  which  point  it  trickles  down  unob- 
served over  the  bladder.  Bleeding  omental  vessels  must  be  tied 
at  once,  for  if  they  are  allowed  to  slip  up  into  the  abdomen  out  of  sight  a 
large  hemorrhage  may  occur  before  discovery,  especially  witii  an  elevated  pelvis. 
If  there  is  obscure  bleeding  from  any  part  of  the  pelvic  cavity  it  may 
be  found  by  putting  in  a  large  dry  sponge  and  waiting  a  while,  when,  on  taking 
it  out,  the  blood  spot  will  show  where  the  flow  is  persistent. 

I  adopt  the  following  precautions  for  controlling  hemorrhage  and  prevent- 
ing its  recurrence :  I  make  it  a  rule  not  to  rely  solely  upon  the  pedicle  liga- 
tures, but  in  addition  to  tie  the  open  mouths  of  all  large  vessels 
with  a  fine  ligature,  making  assurance  doubly  sure.  With  a  little  pa- 
tience slight  bleeding  will  often  cease  spontaneously ;  small  pelvic  vessels,  which 
are  easily  accessible,  may  be  caught  for  a  time  in  artery  forceps,  and  when  the 
forceps  are  removed  the  bleeding  does  not  recur.  Oozing  areas  deep  down  in 
the  pelvis  may  sometimes  be  controlled  by  the  apj^lication  of  hot  water  with 
pressure  upon  a  sponge  or  gauze  pad. 

The  cautery  formerly  much  used  for  this  purpose  ought  to  be  given  up, 
as  it  checks  only  the  smallest  vessels,  which  can  be  better  controlled  in  other 
ways.  One  of  the  best  means  of  stopping  the  flow  from  a  small  area,  whether 
on  intestines  or  uterus  or  j^el vie  floor  low  down,  is  the  application  of  sterilized 
persulphate  of  iron.  A  little  of  the  dry  powder  is  made  to  adhere  to 
the  moistened  finger-tip,  which  is  pressed  firmly  against  the  bleeding  spot  for  a 
minute  or  longer,  and  then  cautiously  removed.  When  there  is  oozing  from  a 
broad  surface  on  the  posterior  lateral  surface  of  the  uterus,  the  easiest  way  to 
control  it  is  by  suturing  tissue  from  the  adjacent  broad  ligament  over  the  area 
and  tying  the  sutures  tight. 

Persistent  hemorrhage  from  a  number  of  branches  of 
the  upper  part  of  the  uterine  artery  may  be  controlled 
l)y  a  ligature  applied  to  the  trunk  of  the  artery  low  down 
near  the  base  of  the  broad  ligament,  in  the  cervical 
region.  The  arterial  trunk  can  be  found  by  drawing  the  body  of  the  uterus 
to  the  opposite  side,  so  as  to  expose  the  broad  ligament  better,  and  then  deter- 


HEMORKHAGE.  27 

mining  the  position  of  the  artery  by  feeling  its  pulsations.  A  ligature  thrown. 
around  it  at  this  point  will  cut  oft"  the  blood  supply  above. 

I  was  obliged  in  one  case  to  resort  to  the  ligation  of  the  internal 
iliac  artery  just  below  the  bifurcation  of  the  common  iliac.  In  removing 
a  cancerous  uterus  through  the  abdomen,  I  had  opened  up  a  diseased  area  at  the 
base  of  the  right  broad  ligament  near  the  pelvic  wall,  and  was  unable  by  ligature 
or  pressure  to  control  the  free  oozing  in  the  already  profoundly  anemic  patient. 
I  fixed  upon  the  position  of  the  internal  iliac  artery  by  locating  the  common 
iliac  and  finding  its  point  of  bifurcation  by  touch.  A  small  incision  was  then 
made  through  the  peritoneum  and  torn  more  widely  open  with  the  fingers,  lay- 
ing the  artery  bare.  The  ureter  seen  close  by  was  lifted  up  out  of  the  way 
toward  the  pelvic  brim.  The  artery  was  now  loosened  from  its  bed,  so  that  a 
ligature  could  be  passed  beneath  it  without  injuring  the  vein.  This  was  done 
and  the  ligature  tied,  the  circulation  controlled,  and  the  patient  recovered.  In 
similar  operations  the  ureter  must  always  be  recognized  and  removed  to  one 
side,  and  the  artery  carefully  isolated  fi'om  the  vein.  In  another  case  in  which 
I  tied  both  arteries,  hoping  to  check  a  cancerous  development,  I  had  the  mis- 
fortune to  puncture  the  left  common  iliac  vein.  Xot  knowing  that  it  was  the 
iHac  vein,  I  tied  it,  and  gangrene  of  the  leg  followed,  necessitating  amputation 
in  the  middle  of  the  thigh.  The  patient  survived,  and  died  in  the  natural  course 
of  the  cancerous  affection. 

If  the  patient  comes  onto  the  operating  table  in  an  anemic  state  and  loses 
blood  freely,  or  if  she  is  rendered  anemic  and  shocked  by  the  loss  of  blood 
during  an  operation,  from  half  a  liter  to  a  liter  of  normal  salt  solution  must  l)e 
given  subcutaneously. 

In  all  simple  operations  upon  the  uterus,  ovaries,  and  tul)es,  uncomplicated 
by  adhesions,  hemorrhage  within  the  abdomen  must  arise  from  one  of  the  four 
principal  vessels,  uterine  or  ovarian.  Hemorrhage  after  the  removal  of  tubes 
and  ovaries,  or  of  an  ovarian  tumor,  is  always  from  one  of  the  extremities  of  the 
broad  ligament  at  its  pelvic  or  its  uterine  end  ;  if  it  comes  from  the  outer  ex- 
tremity, the  ovarian  vessels  are  bleeding ;  if  from  the  inner  extremity,  at  the 
c  o  r  n  u  uteri  the  uterine  vessels  furnish  the  flow.  These  vessels  are  all  accessi- 
ble, and  can  readily  be  controlled  by  an  additional  ligature  passed  beneath  the 
bleeding  point. 

Hemorrhage  from  tlie  ovarian  vessels  occurring  during  the 
operation,  after  they  have  been  ligated,  comes  from  cutting  too  close  to  the  liga- 
ture, or  from  a  careless  handling  of  the  surrounding  tissues  which  serves  to  drag 
the  pedicle  out  from  under  its  ligature.  This  is  especially  liable  to  happen  in 
sponging  out  the  pelvis,  and  in  putting  tension  upon  the  broad  ligaments  to 
remove  an  ovary  and  tube  from  the  opposite  side.  The  bleeding  area  appears 
as  a  long,  dark,  oval  slit  on  top  of  the  l)road  ligament  extending  out  over  the 
superior  strait.  This  accident  may  be  corrected  l)y  catching  the  outer  extremity 
of  the  broad  ligament  with  forceps  and  lifting  it  well  up  from  the  pelvis  in  order 
to  pass  another  ligature  beneath  the  ovarian  vessels  higher  up.  The  great  dan- 
ger at  this  point  is  that  of  including  the  ureter  in  the  ligature.     This  must  be 


28       PKINCIPLES   AND    COMPLICATIONS    COMMON   TO    ABDOMINAL    OPERATIONS. 

avoided  by  inspecting  the  ureter  and  seeing  that  it  remains  in  its  normal  position 
and  is  not  picked  np  with  the  vessels.  To  avoid  displacing  the  ligatures  in 
sponging  out  the  pelvis,  two  lingers  should  be  introduced  into  the  wound,  the 
index  finger  to  hold  the  uterus  forward,  and  the  middle  finger  resting  on  the 
promontory  of  the  sacrum ;  between  these  the  sponge  may  be  easily  carried  into 
all  parts  of  the  posterior  pelvis  without  striking  the  tops  of  the  broad  ligaments 
and  straining  the  ligatures.  In  cases  of  pelvic  inflammatory  disease,  the  tearing 
loose  of  the  ovary  from  its  hilum  during  enucleation  often  gives  rise  to  free 
hemorrhage.  The  remedy  for  this  accident  is  to  clamp  the  bleeding  vessels  with 
two  or  more  forceps,  and  then  to  tie  the  main  trunks  at  either  extremity  by  pass- 
ing two  or  more  ligatures  through  the  broad  ligament. 

Hemorrhage  from  the  uterus,  bladder,  or  intestines  can 
"Usually  be  controlled  by  passing  a  fine  ligature  beneath  the  bleeding  point  with- 
out penetrating  the  cavity  of  the  viscus,  drawing  the  knot  just  tight  enough  to 
check  the  flow.  An  important  principle  to  be  observed  in  the  ligation  of  a 
bleeding  vessel  deep  down  in  the  pelvis  and  difficult  of  access,  or  oozing  so 
active  as  to  obscure  the  field,  is  to  introduce  and  tie  a  ligature  as  near  the 
point  as  possible.  If  this  does  not  control  the  hemorrhage,  it  will  at  least  be  in 
close  proximity  to  the  source,  and  so  serve  as  a  tractor  to  draw  the  tissue  up 
into  better  view  while  another  ligature  is  applied,  followed,  if  necessary,  by  a 
third  and  a  fourth.  It  is  occasionally  necessary  to  pass  olie  ligature  below  the 
other  in  this  way  halfway  down  the  broad  ligament  before  a  dry  field  is  secured. 

When  the  hemorrhage  is  too  general  to  be  controlled  by  the  above  means, 
or  when  the  life  of  a  patient  is  likely  to  be  jeopardized  by  the  length  of  time 
necessary  to  control  a  number  of  bleeding  points,  a  gauze  drain  must  be  used. 
If  packed  tightly,  it  acts  as  an  efiicient  hemostatic  and  removes  the  blood  as 
well.  This  method  of  controlling  bleeding  will  only  be  necessary  in  rai-e  in- 
stances if  the  foregoing  means  are  faithfully  employed. 

Irrigation. — The  best  means  of  cleansing  the  peritoneum  after  contamination 
by  septic  discharges,  blood,  or  the  debris  from  tumors,  is  to  wash  out  the  abdo- 
men with  a  normal  salt  solution.  Pouring  the  hot  solution  into  the  abdomen 
also  serves  an  excellent  purpose  as  a  stimulant.  But  irrigation,  although  invalu- 
able in  some  cases,  should  not  be  resorted  to  frequently.  When  there  has  been 
moderate  hemorrhage,  limited  to  the  pelvis,  the  blood  should  be  gently  removed 
with  sponges,  and  any  small  amount  remaining  will  be  absorbed  without  difii- 
culty.  Even  the  escape  of  a  small  quantity  of  pus  does  not  require  irrigation,  if 
it  is  at  once  taken  up,  and  if  the  microscoj)e  shows  that  it  is  sterile  or  contains 
but  few  germs.  When,  however,  the  removal  of  a  large  adherent  ovarian  or 
myomatous  tumor  has  been  accompanied  with  considerable  hemorrhage,  or  when 
a  large  pus  sac  has  ruptured  in  the  pelvis  and  the  pus  has  been  found  distributed 
among  the  intestines,  and  wlien  the  intestines  have  been  sutured,  then  thorough 
irrigation  is  necessary  for  tlie  purpose  of  diluting  and  removing  infectious  mate- 
rial which  can  not  be  taken  up  so  well  by  sponges.  Pure  water  is  irritating  to 
the  peritoneum,  and  for  this  reason  the  normal  salt  solution  (six  tenths  of  one 
per  cent)  is  employed  as  the  irrigating  fluid.     Before  every  abdominal  operation 


EXPERIMENTAL   STUDY    OF   DRAIXAGE.  20 

a  flask  of  tlie  solution  sliould  be  placed  on  tlie  sand  bath  and  brought  to  43-3°  to 
4A:'4:°  C.  (110°  to  112°  F.),  as  indicated  by  a  long  thermometer  standing  in  it. 
A  more  convenient  method  is  to  bring  one  flask  to  the  boiling  point  and  have 
a  second  cold  one  ready  to  mix  with  it,  reducing  it  at  once  to  the  desired  temper- 
ature. To  mix  them  I  use  a  graduated  glass  pitcher,  devised  by  Dr.  H.  Robb, 
provided  with  a  fixed  thermometer.  To  use  irrigation,  the  solution  is  poured 
into  the  abdominal  cavity  by  a  nurse  or  assistant.  By  making  a  funnel  of  the 
palmar  surface  of  the  hand,  the  operator  can  direct  the  fluid  into  the  pelvis  or 
up  into  any  part  of  the  abdomen  among  the  intestines.  AVhen  the  infection  is 
limited  to  the  pelvis,  care  must  be  exercised  not  to  let  the  water  flow  up  among 
the  intestines,  which  serves  to  distribute  more  ^\^dely  the  infection.  This  is  done 
in  two  ways — by  keeping  the  incision  widely  open,  so  that  it  affords  the  easiest 
avenue  of  escape  for  the  water,  and  by  avoiding  the  use  of  too  much  water  at 
one  time,  A  little  is  poured  in  and  swabbed  about  in  the  pelvis  with  a  sponge 
and  removed,  then  a  little  more,  and  so  on.  The  upper  abdominal  cavity  can 
be  better  washed  out  if  the  pelvis  is  elevated  when  the  water  is  poured  ;  in  this 
way  it  will  often  receive  a  liter  or  more  before  overflowing.  By  letting  the 
pelvis  down,  the  fluid  either  escapes  or  is  easily  sponged  out.  This  may  be  re- 
peated any  number  of  times.  I  have  used  as  much  as  13  liters  in  this  way  to 
wash  out  the  blood  from  a  ruptured  extra-uterine  pregnancy  which  had  accu- 
mulated under  the  liver.  In  drying  out  the  abdomen  the  renal  fossse  must  not 
be  forgotten,  as  a  considerable  quantity  of  fluid  is  liable  to  accumulate  there. 

In  septic  cases  the  sponges  must  be  separated,  and  those  which  have  been 
employed  in  removing  pus  from  a  ruptured  abscess  must  be  laid  aside  and  not 
be  used  later  in  cleansing  out  the  abdomen.  Another  efficient  method  of  irri- 
gating is  by  means  of  a  long  glass  douche  nozzle  connected  by  rubber  tubing 
with  a  large  funnel ;  in  this  way  the  fluid  can  be  directed  to  any  part  of  the 
abdomen,  and  its  force  increased  by  raising  the  funnel.  It  is  a  cardinal  prin- 
ciple not  to  irrigate  over  a  wider  area  than  has  been  contamiTiated.  Thus  the 
pelvis  alone  will  most  frecpiently  need  it,  next  the  lower  abdomen  below  the 
omentum,  and  last  of  all  the  entire  abdominal  cavity  from  diaphragm  to  pelvic 
floor. 

Experimental  Study  of  Drainage. — P  hysiology  of  Drainage  . — When 
to  drain,  how  to  drain,  and  whether  or  not  to  drain  at  all,  are  questions  of  the 
highest  import  in  abdominal  surgery.  There  is  perhaps  no  topic  upon  which 
surgeons  are  more  at  variance  with  one  another  in  their  practice;  for,  while 
some  men  drain  almost  all  their  cases,  even  the  simplest,  others  have  abandoned 
drainage  in  all  but  the  rarest  instances. 

After  an  extensive  experience  with  all  forms  of  drainage,  I  have  myself 
been  slowly  forced  to  the  conclusion  that  it  is  rarely  of  value  and  often  harmful ; 
for  example,  in  the  first  five  hundred  abdominal  sections  performed  in  my  de- 
partment at  the  Johns  Hopkins  nosj)ital,  the  glass  drainage-tube  was  extonsively 
employed — seventy-three  times  in  the  first  one  hundred  cases. 

The  whole  subject  of  drainage  is  one  of  such  fundamental  importance  that  I 
deem  it  necessary  to  present  in  some  detail  the  arguments  drawn  from  nunier- 


30       PRIXCIPLES    AND    COMPLICATIOXS    COMMON   TO    ABDOMINAL   OPERATIONS. 

ous  expei'imental  studies  and  clinical  experience  in  ovei*  two  thousand  of  mv 
cases  to  form  a  basis  from  "vvhicli  to  draw  correct  conclusions.  For  this  purpose 
I  have  drawn  freely  upon  the  work  of  mj  late  assistant  Dr.  J.  G.  Clark  {Johns 
Hopk.  Hasp.  Bull.,  Apr.,  1897). 

F u n c t i o n  o f  the  Peritoneum  u n d e r  N o r m a  1  and  Patho- 
logical Conditions . — G.  AVegner  (  Verhand.  d.  deutsch.  Gesell.  f.  Chir., 
Berlin,  1877),  the  first  investigator  who  by  experiments  U23on  animals  endeav- 
ored to  arrive  at  some  definite  conclusion  as  to  the  ability  of  the  peritoneum  to 
rid  itself  of  injurious  fluids  or  solid  particles,  was  convinced  that  a  comparatively 
large  quantity  of  infectious  matter  could  be  eliminated  or  encapsulated  by  the 
peritoneal  exudate  without  serious  harm  to  the  animal. 

Grawitz  {Char.  Annal.  Jahr.,  xi,  1886)  next  took  up  the  experimental 
study  of  infection  of  the  peritoneum,  pursuing  his  investigations  under  improved 
bacteriological  technique,  and  ai-rived  at  the  following  conclusions : 

1.  The  introduction  of  non-pyogenic  organisms  into  the  abdominal  cavity, 
either  in  small  or  large  quantity,  or  mixed  with  formed  particles,  produces  no 
harm. 

2.  Great  quantities  of  organisms  which  ordinarily  produce  no  symptoms 
may  give  rise  to  a  general  sepsis  if  the  absorptive  function  of  the  peritoneum  is 
impaired. 

3.  Injection  of  pyogenic  organisms  into  the  peritoneal  cavity  may  be  quite 
as  harmless  as  injections  of  non-pathogenic  varieties.  (In  these  experiments  he 
injected  a  flocculent  emulsion  of  staphylococcus  albus  and  aureus  and  the 
streptococcus  pyogenes  in  10  cubic  centimeters  of  water  without  any  visible 
reaction.) 

4.  The  introduction  of  pus-producing  cocci  into  the  normal  peritoneal  cavity 
produces  a  purulent  peritonitis,  first,  if  the  culture  fluid  is  diflicult  of  absorption, 
and,  second,  if  irritating  materials  are  present  which  destroy  the  tissues  of  the 
peritoneum,  thus  preparing  a  place  for  the  lodgment  of  the  organisms  and  the 
production  of  an  exudate  upon  which  they  may  grow. 

Pawlowsky  (  Yirchow's  Arehiv,  No.  117,  p.  469,  1889),  in  an  excellent 
experimental  study,  reviewed  Wegner's  and  Grawitz's  work,  with  whom  he 
agreed  in  many  particulars,  but  disagreed  in  others.  The  main  point  of  diifer- 
ence,  however,  between  Pawlowsky  and  Grawitz  related  to  the  ability  of  the 
normal  peritoneum  to  deal  with  th^  staphylococcus  aui-eus. 

Pawlowsky  found  that  the  large  quantities  of  staphylococci  injected  by 
Grawitz  without  harm  into  dogs  produced  death  very  raj^idlyin  the  animals 
upon  which  he  experimented,  and  that  only  a  minimum  quantity  was  harmless. 

Reichel  {Beat.  Zeit.f.  Chir.,  \kA.  xxx,  1889)  went  over  the  same  ground  in 
an  experimental  research,  and  in  the  main  agreed  with  Grawitz.  The  essen- 
tial points  of  value  in  Reichel's  paper  are,  that  peritonitis  usually  arises,  first, 
because  more  organisms  gain  entrance  than  can  be  handled  by  the  peritoneum, 
and,  second,  because  the  stagnation  of  degenerating  fluids  in  dead  s^iaces  favors 
the  growth  of  the  oi'ganisms. 

He  also  accounts  for  GraAvitz's  and  Pawlowsky's  conflicting  results  on  the 


EXPERIMENTAL   STUDY    OF    DRAINAGE.  31 

ground  that  some  animals  are  more  susceptible  to  infection  than  others,  and 
that  there  are  marked  differences  in  the  virulence  of  cultures  of  the  same  organ- 
ism under  varying  conditions. 

A  carefully  conducted  experimental  research  by  "Waterhouse  ( Virchoic's 
Archiv,  vol.  cxix,  ]).  342,  1890),  carried  out  under  the  oversight  of  Orth,  appears 
to  me  to  settle  satisfactorily  the  question  of  the  ability  of  the  normal  peritoneum 
to  take  care  of  infection. 

He  injected  6  cubic  centimeters  of  a  cloudy  culture  of  staphylococcus  aureus 
into  the  abdominal  cavity  of  dogs,  employing  both  the  methods  of  Grawitz  and 
Pawlowsky,  and  all  of  the  animals  survived.  The  same  results  were  obtained 
with  the  streptococcus,  bacillus  pyocyaneus,  and  the  intestinal  bacteria. 

Waterhouse  then  endeavored  to  simulate  the  conditions  occasionally  met 
with  after  operations  by  introducing  8  cubic  centimeters  of  urine  and  small 
quantities  of  blood  with  the  cultures,  and  again  the  results  were  negative.  If, 
however,  15  to  20  cubic  centimeters  of  fi*esh  blood  were  introduced  into  the 
peritoneal  cavity,  followed  in  a  few  minutes  by  the  staphylococcus  aureus,  severe 
peritonitis  was  produced. 

In  these  experiments  Waterhouse  agi'eed  with  Pawlowsky  and  Grawitz  that 
the  dangers  of  peritonitis  are  increased  by  tardy  absorption  of  fluids,  which  in 
effect  leaves  a  culture  medium  for  the  growth  of  the  organisms. 

After  the  introduction  of  blood  clots  3  centimeters  in  size,  followed  by  the 
staphylococcus  aureus,  death  occurred  from  peritonitis  in  twenty-four  hours. 

Waterhouse  also  found  that  the  purulent  exudate  from  acute  abscesses  is 
extremely  virulent,  2  cubic  centimeters  of  the  staphylococcus  aureus  and  1  cubic 
centimeter  of  the  streptococcus  from  this  source  causing  death  in  twenty -four 
hours.  If  a  very  small  quantity  of  the  pus,  however,  was  introduced  with 
water,  the  animals  frequently  survived. 

After  the  introduction  of  turpentine  with  the  organisms,  as  done  in 
Grawitz's  experiments,  peritonitis  did  not  follow,  which  is  explained  by  Water- 
house  on  the  ground  that  the  organisms  are  rendered  inactive  or  are  killed  by 
the  turpentine.  He  proved  this  point  by  injecting  the  turpentine  first  and 
following  it  in  a  .short  time  w^th  the  infecting  germs;  in  every  instance  the 
animal  died  of  peritonitis. 

Dogs  with  a  strangulation  of  the  intestines  were  easily  infected. 

In  three  instances  the  staphylococcus  aureus  introduced  into  the  peritoneal 
cavity  of  cats  suffering  from  ascites,  was  quickly  followed  by  death  from 
peritonitis,  which  resulted,  as  Waterhouse  sa^^s,  because  there  was  a  favorable 
culture  material,  a  diminished  absorption,  and  an  injury  to  the  peritoneal  endo- 
thelium. 

Biirginsky  {Bcmmg  a  Hell's  Jahreshencht^  vol.  vii,  1891),  in  a  series  of  ex- 
periments, also  came  to  the  conclusion  that  the  discrepancies  in  the  results  of 
Pawlowsky\s  and  Grawitz^s  experiments  were  due  to  variations  in  the  virulence 
of  the  cultures  employed. 

Ilalsted  {Jiifnis  IFopl'.  Ilo.tp.  Bej>.^  vol.  ii,  1891)  confirmed  and  extended  the 
views  of  previous  observers  concerning  the  resistance  of  the  normal  peritoneum 


32       PKINCIPLES    AND    COMPLICATIOXS    COMMON    TO    ABDOMINAL   OPERATIONS. 

to  infection,  and  called  attention  to  the  dangers  of  introducing  pyogenic  organ- 
isms about  a  ligated  or  strangulated  area,  or  in  conjunction  with  insoluble  bodies. 
Pieces  of  sterile  potato  introduced  into  the  peritoneal  cavitj  of  controlled  ani- 
mals were  soon  encapsulated  and  produced  no  disturbance,  but  when  infected 
with  pyogenic  cocci  invariably  caused  peritonitis. 

A  recent  paper  by  Cobbett  and  Melsome  {Journal  of  Pathology  and 
Bacteriology^  1895),  on  Local  and  General  Imriiiinityy  contains  some  valuable 
observations  bearing  upon  the  resistance  of  the  peritoneum  to  infection. 

IS^otwithstanding  the  injection  of  large  quantities  of  virulent  streptococci,  a 
few  of  their  animals  survived.  They  state  that  "  in  those  animals  which  suc- 
cumbed quickest,  free  cocci  were  very  numerous  in  the  peritoneal  exudation, 
and  in  those  which  survived  longest  they  were  either  absent  or  contained  within 
phagocytes." 

These  observers,  in  order  to  discover  how  quickly  the  organisms  disappeared 
from  the  peritoneal  cavity,  killed  two  rabbits  which  appeared  about  to  recover, 
"  In  the  first,  which  had  received  5  cubic  centimeters  of  broth  culture  thirty 
hours  before,  only  one  chain  of  streptococci  was  found  after  prolonged  search, 
but  many  cocci  were  contained  in  cells,  and  broth  inoculated  with  this  fluid 
grew  a  good  culture." 

"  The  second  rabbit  having  shown  no  signs  of  illness  after  an  injection  of  6 
cubic  centimeters  of  anaerobic  broth  culture,  received  next  day  10  cubic  centi- 
meters of  a  similar  material  swarming  with  streptococci.  When  killed  five  and 
a  half  hours  later,  not  only  could  no  streptococci  be  seen,  either  free  or  in  cells, 
but  no  growth  grew  on  cultures  made  from  the  abdominal  fluid." 

From  this  review  of  the  literature  bearing  upon  infection  of  the  peritoneum 
I  make  the  following  summary  : 

1.  Under  normal  conditions  the  peritoneum  can  dispose  of  large  numbers 
of  pyogenic  organisms  without  producing  peritonitis. 

2.  The  less  the  absorption  fi-om  the  peritoneal  cavity  the  greater  the  danger 
of  infection. 

3.  Solid  sterile  particles,  such  as  fecal  matter,  potato,  etc.,  are  partly  ab- 
sorbed and  the  remainder  are  encapsulated  without  the  production  of  peri- 
tonitis. 

4.  Death  may  be  produced  by  general  septicemia  and  not  by  peritonitis, 
where  large  quantities  of  organisms  are  taken  up  by  the  lymph  streams. 

5.  Irritant  chemical  substances  destroy  the  tissues  of  the  peritoneum,  and 
prepare  a  place  for  the  lodgment  of  organisms  which  becomes  the  starting-point 
for  peritonitis. 

6.  Stagnation  of  fluids  in  dead  spaces  favors  the  production  of  peritonitis  by 
furnishing  a  suitable  culture  medium  for  the  growth  of  bacteria. 

7.  The  association  of  infectious  bacteria  with  blood  clots  in  the  peritoneal 
cavity  is  especially  liable  to  produce  peritonitis. 

8.  Traumatic  injury  or  strangulation  of  large  areas  of  tissue  are  strong 
etiological  factors  in  the  production  of  peritonitis  when  associated  with  in- 
fectious matter. 


EXPERIMENTAL  STUDY  OF  DRAINAGE.  33 

The  accumulated  evidence  of  all  these  investigators  proves  beyond  question 
that  the  peritoneum,  under  normal  conditions  or  even  when  greatly  handicapped 
by  disease  or  artificial  conditions,  is  capable  of  overcoming  the  invasion  of  com- 
paratively large  quantities  of  pyogenic  bacteria. 

Mechanism  of  Absorption  of  Fluids  and  Solid  Particles 
in  the  Peritoneal  Cavity . — Recent  investigations  by  Muscatello  (  Vir- 
choid's  Archiv,  1895)  on  the  histology  of  the  diaphragmatic  peritoneum  and 
the  mechanism  of  absorption  of  substances  from  the  peritoneal  cavity,  when 
considered  in  conjunction  ^vith  the  above  conclusions,  give  ample  ground  for  my 
suggestion  of  the  elevated  posture  as  a  prophylactic  measure  against  post-opera- 
tive peritonitis. 

Muscatello  accepts  Bizzozero's  and  G.  Salvioli's  classification  of  the  com- 
ponent parts  of  the  diaphragmatic  peritoneum  which  occur  in  the  following 
order  :  Endothelium,  membrana  limitans,  and  connective-tissue  framework.  Up 
to  the  time  of  Muscatello's  publication,  histologists  were  equally  divided  on  the 
question  of  the  presence  or  absence  of  stomata  between  the  endothelium.  He 
proved  beyond  doubt  that  these  openings  are  optical  illusions,  due  to  the  defect- 
ive preparation  and  staining  of  the  microscopical  sections.  According  to  Musca- 
tello's opinion,  minute  foreign  particles,  leucocytes,  and  fluids  pass  through  open- 
ings between  the  endothelium  of  the  diaphragm  made  by  the  retraction  of  the 
protoplasm  of  the  cells. 

Beneath  the  peritoneal  endothelium  of  the  diaphragm  and  between  the  con- 
nective-tissue fibers  are  open  spaces  i  to  16  micromillimeters  in  diameter,  oc- 
curring in  groups  of  50  to  60,  which  communicate  \yith  the  lymph  vessels.  A 
careful  search  for  these  spaces  failed  to  reveal  them  in  any  other  portion  of  the 
peritoneum. 

G.  Wegner  first  proved  that  the  peritoneum  was  capable  of  absorbing  the 
most  remarkable  quantities  of  fluids,  equivalent  to  3  to  8  per  cent  of  the  bodily 
weight  in  one  hour,  or  the  animaPs  entire  weight  in  twenty-four  hours. 

By  the  injection  of  foreign  particles  suspended  in  a  fluid  medium  into  the 
peritoneal  cavities  of  dogs,  Muscatello  was  able  to  demonstrate  the  existence  of 
an  intraperitoneal  current  which  carried  fluids  and  small  particles  toward  the 
diaphragm,  regardless  of  the  animal's  posture.  The  rate  of  transmission  of  the 
foreign  particles  from  the  peritoneal  cavity  to  their  ultimate  repository,  the 
lymph  glands,  could,  however,  be  increased  or  retarded  by  the  influence  of 
gravity. 

In  those  dogs  which  were  suspended  with  head  down,  carmine  bodies  ap- 
peared in  the  retrosternal  and  thoracic  lymph  glands  in  from  five  to  seven  min- 
utes, while  in  animals  in  which  the  posture  was  reversed  it  was  five  and  a  half 
hours  before  they  could  be  recovered  from  these  glands. 

^fuscatello  proved  that  small  particles  were  carried  from  the  peritoneal  cavity 
into  the  lymph  spaces  of  the  diaphragm  through  the  opening  made  by  the  re- 
traction of  the  endothelium,  then  into  the  mediastinal  lym])hatic  vessels  and 
glands,  then  into  the  blood  current,  by  which  they  were  transported  to  the  vari- 
ous organs  of  the  body,  from  which  they  were  picked  up  by  the  lymph  vessels 
43 


34      PRINCIPLES   AND    COMPLICATIONS   COMMON   TO    ABDOMINAL    OPERATIONS. 

and  deposited  in  the  collecting  glands  of  eacli  organ.  For  this  reason  the  large 
vascular  organs,  such  as  the  liver,  stomach,  spleen,  and  pancreas,  show  the  par- 
ticles first  and  in  the  greatest  numbers,  while  the  lymph  glands  of  the  mesen- 
tery, which  gather  their  vessels  from  a  limited  area  of  the  intestine,  contain  but 
few  of  the  granules. 

The  function  of  the  leucocyte  is  of  especial  importance  in  the 
elimination  of  foreign  particles  from  the  peritoneal  cavity. 

Muscatello  and  other  observers  find,  on  examining  the  precipitate  in  the 
peritoneal  cavity  after  injecting  innocuous  foreign  particles  or  bacteria,  wander- 
ing cells  interspersed  among  the  particles,  some  of  which  are  lightly  laden  with 
granules,  while  others  are  apparently  distended  to  the  point  of  bursting,  and 
still  others  which  have  not  yet  taken  up  their  burdens. 

In  some  instances  where  the  granules  are  too  large  for  one  leucocyte  to  en- 
compass it,  two  or  more  join  forces  to  surround  the  invader.  The  leucocytes 
are  found  in  greatest  abundance  beneath  the  omentum.  From  the  peritoneal 
cavity  Muscatello  traces  the  course  of  the  leucocyte  through  the  channels  above 
described,  and  finally  finds  them  deposited  in  the  lymph  glands  in  various  parts 
of  the  body. 

In  Muscatello' 8  experiments  the  leucocytes  were  able  to  dispose  of  the  innocu- 
ous particles  rapidly  and  without  apparent  ill  effect  to  the  animals.  In  Paw- 
lowsky's,  Cobbett's,  and  Melsome's  experiments,  on  the  other  hand,  the  con- 
ditions were  different,  the  leucocyte  having  to  meet  an  antagonistic  invader.  In 
those  animals  which  survived  the  injection  the  infectious  organisms  were 
quickly  encompassed  by  the  leucocytes  and  carried  into  the  general  circulation, 
while  in  the  fatal  cases  the  peritoneal  exudate  was  found  swarming  with  free 
organisms  and  only  a  comparatively  few  were  enclosed  in  leucocytes. 

The  important  conclusions  are  : 

1.  Large  quantities  of  fluids  may  be  absorbed  by  the  peritoneum  in  a  re- 
markably short  time.     (Wegner.) 

2.  Minute  foreign  particles  are  carried  from  the  peritoneal  cavity  through 
the  diaphragm  into  the  mediastinal  lymph  vessels  and  glands,  and  thence  into 
the  blood,  by  which  they  are  transmitted  to  the  organs  of  the  body,  especially 
those  of  the  abdomen,  and  later  appear  in  the  collecting  lymph  glands  of  these 
organs.     (Muscatello.) 

3.  The  leucocytes  are  largely  the  bearers  of  foreign  particles  from  the  peri- 
toneal cavity.     (Muscatello.) 

4.  There  is  normally  a  current  in  the  peritoneal  cavity  which  carries  fluids 
and  foreign  particles  toward  the  diaphragm,  regardless  of  the  posture  of  the  ani- 
mal, although  gravity  greatly  favors  or  retards  it.     (Muscatello.) 

Historical  Development  of  the  Drainage  Question  in 
my  Clinic. — The  clinical  study  of  a  number  of  my  cases,  as  well  as  several 
post-mortem  examinations,  combined  with  the  bacteriological  researches  of  Drs. 
H.  Kobb  and  A.  A.  Ghriskey  on  the  infection  of  the  tube  tract,  convinced  me 
that  the  glass  drainage-tube  was  often  powerless  to  remove  fluids  from  the  pelvis 
and  was  a  source  of  grave  danger  as  a  channel  of  infection  of  clean  wounds. 


EXPERIMENTAL    STUDY    OF   DIIAIXAGE.  35 

In  a  series  of  sixteen  cases  i^Tohns  Hopk.  Hasp.  Bull.^  July,  1891),  in  which 
the  condition  of  the  drainage-tube  tract  was  studied,  in  nine  no  cultures  were 
secured,  but  in  six  the  staph yloccus  albus  was  found,  and  in  one  the 
staphylococcus  aureus,  and,  notwithstanding  the  most  painstaking  tech- 
nique in  the  care  of  the  drainage-tube,  14  per  cent  of  the  cases  showed  some 
form  of  organism.  My  fears  of  the  transmission  of  infection  through  the  tube 
were  further  increased  by  one  undoubted  case  in  which  an  infection  occurred  at 
the  second  dressing  of  the  tube,  followed  by  extensive  suppuration  of  the  ab- 
dominal wound. 

The  glass  drainage-tube  was  therefore  unconditionally  abandoned ;  I  still, 
however,  felt  the  necessity  of  providing  some  means  of  eliminating  fluids  col- 
lecting in  the  peritoneal  cavity,  and  so  adopted  and  used  the  Mikulicz  gauze  bag 
in  forty  cases.  This  proved  no  more  efficient  than  the  simple  gauze  drain  pro- 
posed by  Fritsch,  which  was  next  used ;  in  January,  1893,  following  Schauta's 
observations,  but  independently,  I  adopted  a  new  plan,  and  in  order  to  de- 
termine whether  drainage  should  or  should  not  be  used,  I  had  cover-glass 
preparations  made  of  all  suspicious  fluids  found  during  an  operation,  and  if 
pathogenic  organisms  were  discovered  I  used  a  gauze  drain.  In  forty -four 
cases  of  pelvic  abscess  examined  for  me  by  Dr.  G.  B.  Miller,  gonococci  were 
found  in  six  cover-glass  preparations,  but  did  not  grow  in  cultures;  the  sta- 
phylococcus epidermidis  albus  was  found  once  in  culture  ;  the  remain- 
ing thirty-seven  cases  were  negative. 

These  results  in  general  coincide  with  the  investigations  of  Menge,  Schauta, 
and  Reymond  and  Magill  {Annals  of  Surgery^  1896).  In  an  examination  of  111 
cases  by  Schauta,  streptococci  and  staphylococci  were  found  four  times  ; 
Menge  has  observed  the  staphylococcus  once  in  twenty-six  cases,  and  Morax 
once  in  thirty-six  cases. 

From  this  time  drainage  was  limited  to  infected  cases,  and  no  cases  were 
drained  simply  because  of  the  numerous  adhesions  separated  and  the  raw  sur- 
faces left  l)ehind.  "When  pus  was  found  and  the  microscope  showed  the  entire 
absence  of  organisms  the  drain  was  not  used.  AVhen  the  organisms  were  sparse 
the  drain  was  not  used.  When  the  gonococcus  was  found  the  drain  was 
never  used  under  any  circumstances.  When  staphylococci  and  the  colon 
bacillus  were  found  in  moderate  numbers  the  drain  was  not  used.  AVhen 
staphylococci  and  the  colon  bacillus  were  found  more  abundantly,  and 
when  the  streptococcus  was  found  in  moderate  numbers,  a  drain  was  used. 

But  a  further  study  of  the  gauze  drains  in  the  few  cases  in  which  I  was  now 
using  them,  led  me  to  the  conclusion  that  they  also  usually  became  infected  after 
operation,  through  the  opening  left  in  the  incision,  and  that  this  infection  might 
occasionally  give  rise  to  a  serious  and  even  a  fatal  result.  Of  my  last  hun- 
dred cases  not  one  has  been   drained. 

Objections  to  Drainage. — To  summarize,  the  foUomng  are  the  most 
important  objections  to  drainage  : 

1.  It  is  unnecessary  to  provide  for  the  removal  of  the  sero-sanguineous  fluid 
poured  out  by  the  wounded  surfaces  after  an  abdominal  operation. 


36       PRINCIPLES   AND    COMPLICATIONS   COMMON   TO    ABDOMINAL   OPERATIONS. 

2.  The  very  presence  of  the  drain  excites  a  freer  flow  from  the  wounded  sur- 
faces than  would  otherwise  take  phiee, 

3.  The  drain  is  an  inefficient  means  of  removing  this  fluid,  and  in  some  cases 
it  even  acts  as  a  phig  to  insure  its  retention. 

4.  Sooner  or  later  the  drain  is  certain  to  convey  an  infection  down  its  track, 
which  may  either  remain  localized,  and  form  a  suppurating  sinus,  or  may  form 
the  focus  of  a  general  peritonitis. 

5.  The  mechanical  act  of  removing  the  drain  may  be  the  means  of  insuring 
the  infection  of  the  entire  tract  through  the  infection  already  existing  in  its 
upper  part. 

6.  The  removal  of  a  gauze  drain  is  usually  attended  by  intense  pain,  and  it 
may  be  the  cause  of  a  prolapse  of  the  intestine  or  of  the  omentum  from  the 
wound. 

7.  In  one  case  in  the  hands  of  an  associate,  a  fatal  hemorrhage  followed  the 
dislodgment  of  a  ligature  at  the  time  of  the  removal  of  the  drain. 

8.  Whenever  the  drain  is  used  largely  the  mortality  is  greater  than  in  a  group 
of  similar  cases  which  are  not  drained. 

9.  With  drainage  such  post-operative  sequelae  as  abnormal  elevation  of  the 
temperature,  persistent  vomiting,  tympany,  vesical  irritation,  and  suppuration  of 
the  abdominal  wound  are  nearly  three  times  as  frequent  as  without  it. 

10.  Post-operative  obstruction  of  the  bowel  and  fecal  fistula  is  more  frequent 
in  drained  cases. 

11.  Hernia  is  a  common  sequel  in  the  drained  cases  (8  per  cent),  while  it  is 
rarely  ever  seen  in  the  cases  which  are  not  drained,  if  the  wound  does  not  sup- 
purate. 

12.  These  remarks  refer  principally  to  the  gauze  drain.  Where  the  glass 
tube  is  used,  perforation  of  the  intestine  and  hernia  into  the  openings  in  the 
tube  occur,  the  area  drained  is  smaller,  and  the  drainage  is  inefiicient. 

In  order  to  arrive  at  a  clearer  determination  of  the  source  and  the  avenue  of 
the  infection  in  the  drained  cases,  I  have  divided  them  into  two  groups,  the  first 
containing  tumors,  cysts,  etc.,  in  which  infection  previous  to  operation  is  rarely 
present,  the  second  including  the  inflammatory  cases,  such  as  pelvic  abscess, 
pyosalpinx,  acute  and  chronic  salpingitis,  and  peri-ooi3horitis. 

In  the  first  class  drainage  was  usually  employed  to  control  oozing  from  adhe- 
rent surfaces  and  to  remove  collecting  fluids. 

Of  one  hundred  of  my  undrained  cases,  where  there  were  more  or  less  ex- 
tensive adhesions,  one  case  was  complicated  by  the  formation  of  a  pelvic  ab- 
scess after  the  operation  ;  in  one  hundred  similar  cases  drained,  pelvic  suppura- 
tion occurred  in  eight,  showing  that  the  drain  was  the  avenue  of  infection  in  a 
number  of  cases  which  would  probably  have  recovered  without  suppuration  if 
all  communication  with  the  exterior  had  been  cut  off  and  the  work  of  absorp- 
tion intrusted  to  the  peritoneum  alone. 

The  Prevention  and  Removal  of  Infection  without 
Drainage . — It  can  not  be  denied  but  that  the  greatest  advancement  along  all 
the  lines  in  abdominal  surgery  has  been  made  during  the  same  j)eriod  in  which 


HOW    AND    WHEN   TO    DRAIN.  37 

the  drain  has  been  gradually  given  up.  Each  improvement  in  technique  tends 
to  lessen  the  chances  of  infection  and  to  minimize  the  demands  upon  the  elimi- 
native  powers  of  the  peritoneum.  Asepsis  has  been  more  perfectly  attained 
before  operation  and  maintained  throughout  its  performance ;  septic  cases  are 
always  treated  last  on  operating  days,  and  after  treating  and  examining  an 
acute  septic  patient,  such  as  a  puerperal  septicemia,  all  operative  work  is  aban- 
doned for  three  days ;  in  this  I  accord  with  the  conclusions  reached  by  Zweifel. 

The  technique  of  the  operation  is  better  in  the  more  perfect  control  of  hem- 
orrhage, in  the  better  suturing  and  covering  in  of  raw  surfaces,  as  well  as  in  the 
protection  of  the  peritoneum  from  contamination  by  infected  foci,  and  in  the 
lessened  bruising  of  the  tissues  either  by  unnecessary  manipulation  or  by  undue 
traction  upon  the  edges  of  the  abdominal  incision. 

The  peritoneal  cavity  is  also  no  longer  washed  out  in  a  routine  manner 
merely  because  of  adhesions  and  hemorrhage  ;  when  seriously  contaminated 
by  an  infected  focus,  the  washing  out  is  done  mth  a  definite  purpose  and  is  made 
thorough. 

How  and  "When  to  Drain. — P ostural  Drainage . — Following  the  initia- 
tive of  my  assistant  Dr.  J.  G.  Clark,  and  in  a  practical  way  utilizing  the  experi- 
ments of  Muscatello,  where  there  is  any  serious  contamination  of  the  peritoneum 
and  therefore  danger  of  infection,  from  500  to  1,000  cubic  centimeters  of  a 
normal  saline  solution  are  left  in  the  peritoneal  cavity  after  operation,  and  the 
patient  is  placed  in  a  bed  with  the  foot  elevated  eighteen  inches  for  twenty-four 
hours. 

This  serves  to  dilute  and  promote  the  rapid  absorption  of  all  noxious  mate- 
rial by  calling  into  active  play  the  diaphragmatic  lymph  spaces. 

Cases  to  be  Drained . — The  drain  should  be  used  in  abscesses  which 
are  walled  off  from  the  peritoneal  cavity  and  which  can  not  be  enucleated,  as  in 
appendicitis  or  extensive  suppuration  in  the  pelvis,  where  the  abscess  can  not 
be  reached  and  drained  into  the  vagina. 

A  drain  is  also  called  for  in  cases  of  widespread  peritoneal  suppuration, 
where  the  patient  is  too  feeble  to  be  treated  as  proposed  by  Dr.  J.  M.  T.  Finney 
(see  Chapter  XXII). 

A  prophylactic  drain  must  also  be  used  when  the  intestine  has  been  sutured 
and  there  is  doubt  as  to  the  accuracy  of  the  suturing,  or  of  the  ability  of  the 
tissues  to  hold  the  sutures. 

II ow  to  put  in  and  take  out  a  Drain. — The  pieces  of  gauze 
used  for  the  drain  are  folded  twice  and  stitched  along  the  edge ;  they  are  (i0 
centimeters  (20  inches)  long  and  4  to  6  centimeters  wide.  Gauze  is  prepared  for 
use  according  to  the  formula  given  in  Chapter  I ;  but  before  insertion  it  is  im- 
mersed in  water  and  squeezed  out,  to  remove  the  excess  of  iodoform,  making  a 
"  washed-out  iodoform  gauze  drain  "  ( Siinger). 

In  order  to  place  the  drain  ctTeetiv-ely  within  the  abdomen  it  is  cither  rolled 
in  a  loose  coil  like  a  ball  of  string,  so  as  to  pull  out  from  the  center,  and  so  laid 
in  the  pelvis  over  the  area  to  be  drained,  or  it  is  packed  in  loose  layers  from 
side  to  side  so  that  it  can  not  become  tangled  in  the  removal,  until  the  space  is 


38       PKINCIPLES    AND    COMPLICATIONS    COMMON    TO    ABDOMINAL    OPERATIONS. 

filled.  This  is  best  done  with  the  pelvis  slightly  elevated,  to  keep  the  intestines 
out  of  the  way  until  the  gauze  is  adjusted.  The  end  coming  out  of  the  center 
of  the  ball  lies  in  the  lower  angle  of  the  incision. 

In  the  rare  cases  in  which  it  is  justifiable  to  drain  for  persistent 
hemorrhage  a  number  of  gauze  strips  may  be  packed  firmly  against  the 
bleeding  surfaces  by  folding  the  gauze  upon  itself  from  side  to  side.  The  end 
of  each  piece  must  be  brought  out  externally  and  so  marked  that  the  last  intro- 
duced can  be  recognized  and  removed  first.  I  had  one  case  in  which  the  end 
of  one  piece  was  not  brought  out,  and  in  consequence  the  gauze  stayed  in  the 
abdomen  six  weeks,  and  was  only  discovered  and  pulled  out  as  the  patient  was 
ready  to  leave  the  hospital. 

If  the  area  needing  drainage  is  extensive,  a  large  quan- 
tity of  gauze  should  be  used  without  hesitation.  I  have  in 
this  way  even  filled  the  whole  lower  abdominal  cavity.  In  the  case  of  an  old 
woman  with  an  ovarian  tumor  extensively  and  densely  adherent,  where  the  pulse 
went  up  over  two  hundred  and  it  was  out  of  the  question  to  take  time  to  stop  a 
general  oozing,  I  tore  up  large  gauze  pads  and  filled  the  left  side  and  whole 
lower  abdomen  with  them.  There  was  a  free  discharge  for  a  few  days,  when 
the  pack  was  removed  and  recovery  followed. 

Where  there  is  a  widespread  infection  and  general  perito- 
nitis, drainage  through  the  median  line  over  the  pelvis  will  not  suflice.  In 
this  case  one  or  more  lateral  or  posterior  openings  must  be 
provided  as  well.  I  can  best  demonstrate  the  value  of  this  way  of  drain- 
ing by  citing  a  typical  case.  I  had  operated  upon  a  very  stout  woman  with  a 
large  extra-uterine  sac  by  opening  and  draining  it  i^er  vaginam.  The  sac  was 
irrigated  daily  with  a  saturated  boric-acid  solution,  and  about  the  fifth  day  the 
nurse  pushed  the  point  of  the  glass  nozzle  through  the  thin  sac  wall  into  the 
abdominal  cavity  and  forced  a  liter  of  the  solution  into  it.  This  was  continued 
for  two  days,  when  the  patient  developed  a  violent  general  peritonitis  and  I  was 
obliged  to  open  the  abdomen  hurriedj  /■  by  night,  when  I  washed  out  a  large 
quantity  of  fiuid  filled  with  flakes  of  lymph,  and  found  a  universal  adhesive 
peritonitis.  The  patient  was  in  a  low  condition  and  all  the  steps  of  the  opera- 
tion had  to  be  hurried  to  get  her  off  the  table  with  any  chance  at  all  of  recovery. 
The  abdomen  was  well  washed  out  and  a  large  pack  placed  in  the  pelvis,  another 
pack  extended  from  the  incision  out  toward  the  right  flank,  and  a  third  to  the 
left.  Free  openings  for  drainage  were  also  made  in  each  flank  in  front  of  the 
erector  spinse  muscles  by  pushing  out  the  abdominal  wall  with  a  hand  in  the 
abdomen  and  cutting  boldly  with  a  knife  from  without  inward  through  all  its 
layers  at  once.  These  incisions  were  about  6  centimeters  (2|^  inches)  long,  and 
the  tendency  of  their  thick  walls  to  drop  together  was  prevented  by  drawing 
the  peritoneum  out  over  the  muscles  and  suturing  it  to  the  skin.  A  large  gauze 
drain,  communicating  with  the  drains  above,  was  stuffed  into  each  flank  and 
brought  out  at  these  openings.  The  patient's  life  was  saved  by  this  extensive 
free  drainage.  I  have  adopted  this  plan  on  several  other  occasions  with  like 
success. 


HOW    AXD    WHEN   TO    DRAIX.  39 

"WTiile  the  incision  must  be  left  well  open  for  the  drain  to  discharge  freely 
out  on  the  surface,  too  large  an  opening  should  not  be  left,  because  in  vomiting 
or  coughing  some  coils  of  intestines  may  be  forced  through.  On  the  other  hand, 
it  must  not  be  made  too  small,  so  as  to  check  the  outflow  of  the  discharges.  To 
this  end  the  pieces  of  gauze  coming  out  on  the  surface  should  fit  the  opening 
snugly  without  either  being  loose  or  constricted.  The  point  of  greatest  danger 
of  protrusion  is  at  the  upper  angle  of  the  opening  just  above  the  gauze.  If  an 
evident  opening  remains  here  after  the  drain  is  in  place,  an  additional  piece  of 
gauze  must  be  introduced,  extending  well  above  the  incision  and  filling  the  gap. 

Where  the  walls  are  usually  thick  there  is  a  tendency  to  drop  together  and 
impede  the  outflow ;  in  these  cases  it  is  well  sometimes  to  fasten  the  peritoneum 
with  a  few  sutures  just  under  the  skin,  converting  the  long  channel  into  a  nar- 
rower neck.  After  two  or  three  days,  as  the  drain  is  removed,  the  sutures  can 
be  cut  and  the  peritoneum  falls  back  in  place. 

When  there  is  a  reasonable  prospect  at  the  time  of  operation  that  the  drain 
may  be  removed  in  two  or  three  days,  several  silkworm-gut  sutures  should  be 
placed  in  the  incision  through  all  the  layers,  and  left  untied  until  the  drain  is 
taken  out,  when  they  are  drawn  up  and  the  wound  completely  closed.  The 
wound  above  the  drain  may  be  closed  at  the  completion  of  the  operation  in  the 
usual  manner,  by  bringing  the  peritoneum  together  with  a  continuous  suture  and 
uniting  the  fascia  and  skin  with  interrupted  silkworm-gut  sutures. 

The  dressing  over  the  drain  consists  of  layers  of  absorbent  gauze 
and  cotton,  covering  it  well  on  all  sides,  and  being  sufficient  in  quantity  to  take 
up  all  discharges.  These  should  be  removed  as  often  as  they  are  saturated  by 
taking  them  up  with  sterilized  forceps.  Much  depends  upon  the  time  at  which 
the  drain  is  taken  out,  for  with  an  early  removal  and  closure  of  the  incision  the 
annoyance  of  a  fistulous  tract  is  avoided. 

In  removing  the  dressings  over  the  drain,  or  in  taking  it  out,  extreme  anti- 
septic precautions  should  always  be  used,  and  these  should  never  be  intrusted  to 
a  nurse.  The  bedclothes  are  turned  down  and  the  nightgown  drawn  up ;  the 
bandage  is  then  thrown  open  and  sterilized  towels  laid  on  all  sides,  covering  the 
al)domen.  The  dressings  are  then  picked  up  vnth.  forceps  and  removed  down  to 
the  drain.  If  there  is  no  infection  it  is  best  to  remove  the  drain  in  thirty-six 
hours ;  in  infected  cases  it  may  be  slowly  delivered  in  the  course  of  four  or  five 
days  or  longer.  To  remove  the  drain  the  end  of  the  gauze  is  seized  and  t^visted 
to  make  it  smaller  and  to  loosen  it  from  the  edges  of  the  incision ;  it  is  then 
slowly  withdrawn,  continuing  to  twist  it  all  the  time.  If  some  free  flow  follows 
the  removal  of  the  first  part,  it  is  well  to  cut  it  off  and  remove  the  rest  later. 
If  the  patient  suffers  much  from  the  attempt  to  take  the  drain  out  it  will  be 
wiser  to  administer  a  little  chloroform. 

Infection  of  the  drainage  tract  is  to  be  expected  when  the  pelvis  has  been 
the  seat  of  a  virulent  infection.  This  is  commonest  when  staphylococcus  aureus 
and  streptococci  are  found  in  abundance  in  the  pus.  With  the  glass  drainage- 
tube  the  case  was  quite  different ;  infection  of  the  tract  occurred  frequently,  and 
often  after  the  simplest  operations.     In  such  a  case  the  gauze  nmst  be  taken  out 


40       PRINCIPLES   AND    COMPLICATIONS    COMMON   TO    ABDOMINAL   OPERATIONS. 

slowly  and  fresh  pieces  put  in  to  keep  the  wound  from  following  its  natural  ten- 
dency and  closing  first  in  the  upper  part.  After  ten  days  the  tract  may  be  irri- 
gated down  to  the  bottom  and  kept  clean  with  peroxide  of  hydrogen.  A  strep- 
tococcus wound,  and  the  fistula  left  by  draining  a  tuberculous  peritonitis,  are 
both  obstinate  affections  and  may  take  months  to  close.  If  numerous  and  heavy 
silk  ligatures  have  been  used  the  fistula  will  not  close  until  they  have  all  been 
fished  out  with  a  crochet  needle. 

]^ow  that  a  few  fine  silk  sutures  and  catgut  sutures  have  replaced  the  heavy 
cable  suture  formerly  used  for  pedicles  and  in  ligating  large  vessels,  a  fistulous 
tract  is  rarely  found  kept  patulous  by  a  bunch  of  ligatures. 

Closure  of  the  Incision. — A  proper  closure  of  the  incision  is  of  the  utmost 
importance,  as  by  an  incorrect  apposition  of  its  layers  the  walls  may  be  so  weak- 
ened as  to  favor  the  formation  of  a  hernia.  It  should  also  be  an  object  in  a 
good  closure  to  leave  a  fine  linear  scar,  which  is  neither  unsightly  nor  a  source 
of  annoyance  to  the  patient.  It  must  be  acknowledged  at  once  that  no  plan  of 
closure  can  really  restore  the  parts  to  their  primitive  condition,  for  we  have  no 
way  of  replacing  the  strong  fibrous  interlacement  of  the  linea  alba.  The 
best  method  of  closure  is  that  which  brings  the  tissues  into 
exact  approximation  layer  by  layer  in  the  order  they  occu- 
pied before  division,  and  holds  them  there  until  firmly  united, 
with  the  least  risk  of  infection.  Experience  has  shown  that  the  four 
important  layers  in  the  abdominal  wall  in  the  median  line  are  the  peritoneum, 
the  fascia,  the  fat,  and  the  skin.  A  good  early  union  of  the  peritoneum  pre- 
vents infection  from  invading  its  cavity  from  without  in  case  of  suppuration 
in  the  wound.  The  fascia  is  the  source  of  strength  in  holding  the  two 
sides  together  and  preventing  hernia,  and  by  uniting  the  fascia  the  recti  muscles 
in  their  sheaths  are  necessarily  held  also,  and  therefore  need  no  sj^ecial  suture. 
The  apposition  of  the  fat  obliterates  the  dead  space  in  which  blood  is  likely  to 
accumulate  if  it  is  neglected,  and  thus  prevents  infection.  The  union  of  the 
skin  prevents  contamination  from  without,  especially  by  the  white  skin  staphy- 
lococcus. 

The  first  step  in  the  closure  common  to  all  methods  is  to  unite  the  peri- 
toneum from  top  to  bottom  by  a  continuous  fine  catgut  suture  ;  before  tying  th& 
suture  at  the  lower  end,  any  air  in  the  peritoneal  cavity  may  be  expelled  by  mak- 
ing pressure  with  the  hands  on  the  sides.  The  skin  and  strong  fascia  overlying 
the  recti  muscles  are  next  united  in  one  of  two  ways.  First,  by  a  series  of  inter- 
rupted silkworm-gut  sutures,  each  one  of  which  enters  on  the  skin  surface  half 
a  centimeter  from  the  edge,  and  then  passes  through  the  fat  and  the  fascia  of 
that  side  ;  the  suture  then  crosses  the  wound  and  catches  up  the  fascia  of  the 
opposite  side,  and  emerges  on  the  skin  at  a  point  corresponding  to  that  of  en- 
trance. If  the  fascia  has  retracted  it  may  be  drawn  out  with  forceps  before 
transfixing  it.  It  is  not  necessary  to  pierce  the  muscles.  All  hemorrhage  must 
cease  before  the  sutures  are  tied.  A  sponge  should  be  lightly  squeezed  out  in 
bichloride  solution  (1-1000)  and  rubbed  well  into  the  interstices  of  the  wound. 
This  should  be  followed  by  a  light  rinsing  with  sterile  water.     Where  vessels. 


CLOSURE    OF   THE    INCISION.  41 

in  the  incision  continue  to  bleed,  fine  ligatures  must  be  applied  ;  othen\'ise  there 
will  be  a  collection  of  blood  beneath  the  skin  breaking  down  later.  These  silk- 
worm-gut sutures  should  be  applied  about  1  centimeter  apart.  I  generally  put 
them  all  in  first,  and  then  tie  them  afterward.  Fine  superficial  catgut  sutures 
between  the  silkworm  gut  give  accurate  approximation  throughout.  This  form 
of  suture,  which  was  at  one  time  extensively  used,  is  now  restricted  to  cases  in 
which  it  is  necessary  to  close  the  incision  in  a  hurry,  or  where  there  is  malignant 
disease  and  there  is  no  prospect  that  the  patient  will  ever  subject  her  abdominal 
muscles  to  much  strain. 

The  second  method  is  always  the  best  in  an  aseptic  case ;  after  closing 
the  peritoneum  with  the  continuous  catgut  suture,  the  retracted  fascia  is 
pulled  out  on  both  sides  with  artery  forceps  and  held  while  it  is  being  united 
from  side  to  side  by  mattress  silver-wire  sutures  extending  12  millimeters  back 
of  the  cut  side  and  embracing  about  12  millimeters  of  the  tissue,  and  placed 
about  4  or  5  centimeters  apart.  The  suture  is  drawn  snugly  up  but  not  too 
tight,  and  then  twisted  five  times,  caught  with  the  artery  forceps,  cut  off,  and 
the  end  turned  down  so  as  to  lie  on  the  fascia  horizontally,  the  end  neither 
projecting  upward  nor  downward.  The  effect  of  this  row  of  sutures  is  to  quilt 
the  strong  fibrous  sheath  together  in  a  ridge  from  top  to  bottom;  between 
these  sutures  interrupted  catgut  sutures  are  used  to  insure  accurate  union 
throughout ;  silkworm  gut  may  be  used  in  place  of  silver  wire. 

Short  wounds,  less  than  6  centimeters  long,  may  be  safely  closed  with  catgut 
throughout,  buried  sutures  to  the  peritoneum  and  fascia,  and  subcuticular  to 
the  skin. 

The  subcutaneous  fat  is  brought  into  close  apposition  by  a  continuous 
catgut  suture.  The  importance  of  this  can  not  be  insisted  upon  too  strongly. 
If  omitted,  a  dead  space  will  be  left  for  the  collection  of  blood,  which  is 
likely  to  become  infected  and  cause  an  abscess. 

The  skin  w  o  u  n  d  is  then  closed  Avith  a  continuous  subcuticular  fine 
catgut  suture,  beginning  in  one  end  of  the  wound  and  ending  in  the  other.  Each 
time  the  suture  is  carried  from  one  side  to  the  other  it  grasps  from  2  to  3  milli- 
meters of  the  tough  corium.  This  last  suture  is  absorbed  in  from  nine  to  twelve 
days,  while  the  silver  wire  remains  buried.  The  advantages  of  this  plan  are 
a  firm  closure,  freedom  from  stitch-hole  abscess,  diminished  liability  to  horuia, 
and  simplicity  of  after-treatment  (see  Fig,  521). 

When  the  um1)ilicus  is  cut  through,  it  is  well  to  split  it  on  each  side  before 
putting  in  the  sutures,  to  convert  the  naturally  thin  surface  between  the  skin 
and  peritoneum  into  a  broader  area  for  better  approximation. 

Hematoma. — If  the  bleeding  vessels  in  the  subcutaneous  fat  are  not  all 
controlled  at  the  time  of  the  operatiou  a  hematoma  may  form  under  the  skin, 
where  it  remains  for  a  few  days  or  a  week  as  an  indolent  tumoi-,  and  then  either 
escapes  through  the  incision,  or,  in  the  majority  of  cases,  suppurates.  The 
hematoma  may  form  rather  in  the  form  of  a  slight  swelling  with  a  marked  dis- 
coloration of  the  adjacent  skin  area,  or  it  may  forui  a  distinct  lump,  like  a  mar- 
ble or  a  pigeon's  egg,  under  the  skin  without  discoloration. 


42       PRINCIPLES    AND    COMPLICATIONS    COMMON   TO    ABDOMINAL    OPERATIONS. 

The  temperature  is  not  affected  until  infection  has  occurred.  The  pain  is 
usually  not  more  than  a  slight  discomfort. 

The  treatment  is  incision  and  evacuation  ;  this  maj  be  done  by  freezing  the 
surface  with  ethyl  chloride  and  then  making  a  small  incision  with  a  sharp 
bistoury,  either  through  the  original  wound  or  over  the  most  prominent  point. 


Fig.  32L — Closure  of  the  Abdominal   Wound. 

The  fascia  is  seen  closed  in  the  bottom  of  the  wound  by  mattress  sutures  of  silver  wire  with  catgut 
between  them.  The  skin  is  being  closed  by  the  continuous  subcuticular  catgut  suture ;  the  lower  angle  of 
the  wound  is  snu;^ly  closed,  while  above  this  the  suture  has  not  yet  been  pulled  up.  The  needle  takes  up 
each  time  a  little  bit  of  the  coriuin,  but  does  not  appear  at  any  place  on  the  skin  surface. 


A  little  pressure  at  the  sides  serves  to  turn  out  some  of  the  clots  and  the  fluid 
contents.  The  wound  is  then  dressed  aseptically,  and  heals  without  suppu- 
ration. 

The  Abdominal  Dressing. — After  the  incision  has  been  closed,  it  should  first 
be  sponged  with  water,  followed  by  bichloride  of  mercury  solution  (1-1,000), 
after  which  the  surrounding  parts  are  cleansed  and  dried.  Care  should  be  ob- 
served not  to  cleanse  the  surrounding  parts  and  then  to  sponge  the  wound  with 
the  same  gauze  or  sponge.  A  square  of  sterilized  gauze,  six  or  eight  layers  in 
thickness  and  large  enough  to  project  5  to  10  centimeters  (2  to  4  inches)  beyond 
the  incision,  is  spread  over  the  wound.  When  buried  sutures  are  used  the  wound 
is  protected,  acording  to  Ilalsted's  plan,  by  films  of  silver  foil,  which  cling  close 
to  the  skin,  acting  both  as  an  occlusive  and  an  antiseptic  dressing.  A  gauze 
pad  is  also  applied  over  this  and  held  in  place  by  adhesive  strips. 


THE    ABDOMIJSTAL   DRESSING.  43 

Abundant  layers  of  sterilized  cotton  are  placed  over  this,  and  the  Scultetus 
bandage  over  all.  The  Scultetus  bandage  is  a  sort  of  T-bandage  made  of  six 
canton  flannel  straps,  four  abdominal  straps,  laid  edge  to  edge,  at  right  angles, 
across  two  perineal  straps,  and  all  stitched  together.  Each  piece  is  10  centi- 
meters (4  inches)  wide  and  about  55  centimeters  (22  inches;  long,  varying  in 
length  according  to  the  size  of  the  patient. 

In  putting  it  on,  the  body  of  the  bandage  goes  behind,  with  its  lower  edge 
about  on  a  level  with  the  head  of  the  femur.  Then  beginning  at  the  top,  the 
first  strap  is  drawn  firm  and  flat,  obliquely  down  across  the  abdominal  dressing, 
first  on  one  side  and  then  on  the  other.  The  next  strap  overlaps  this,  and  so  on 
to  the  lowest,  which  is  bound  straight  across.  The  abdominal  straps  which  are 
imbricated  in  this  way  are  held  in  place  by  the  perineal  straps,  which  are  drawn 
snugly  up  between  the  thighs  and  fastened  to  all  the  others  -with  safety  pins. 

When  the  convalescence  is  miinterrupted  the  bandage  is  removed  when  it 
becomes  soiled,  but  the  cotton  and  gauze  dressings  remain  undisturbed  until  the 
tenth  day,  when  the  catgut  suture  will  have  become  absorbed,  and  the  skin  union 
is  perfect.  Where  the  skin  has  been  carefully  apposed  by  the  subcuticular  suture 
the  cicatrix  will  often  be  so  minute  as  to  be  overlooked,  except  upon  the  closest 
inspection. 


CHAPTEE  XXI. 

CARE  OF  "WOUND  AND  PATIENT  UP   TO   RECOVERY. 

1.  Position  in  bed. 

2.  Toilet. 

3.  Sedatives. 

4.  Nausea. 

5.  Thirst. 

6.  Irritability  of  bladder  and  decrease  of  urinary  excretion. 

7.  Food. 

8.  Catheter. 

9.  Bowels. 

10.  Tympany. 

11.  Temperature — a.  Temperature  and  pulse  chart. 

12.  Pulse. 

13.  Facial  expression. 

14.  Wound. 

15.  Bandage. 

16.  Exercise. 

The  after-treatment  of  most  cases  following  abdominal  operations  is  usually 
of  a  definitely  routine  character.  But  certain  minor  disturbances,  more  or  less 
closely  simulating  serious  complications,  may  arise  and  assume  importance  from 
the  standpoint  of  a  differential  diagnosis. 

Abdominal  operations  are  always  attended  by  more  or  less  depression,  vary- 
ing in  intensity  according  to  the  vitality  of  the  patient,  the  loss  of  blood,  and 
the  length  of  the  operation. 

"While  the  patient  is  still  in  the  operating  room  the  bed  has  been  prepared 
for  her  by  placing  a  broad  rubber  sheet  under  the  linen  draw  sheet  on  which  she 
lies  and  a  single  blanket  between  the  patient  and  upper  sheet,  to  be  removed 
after  the  patient  has  reacted  ;  the  pillow  is  removed,  and  several  hot-water  cans 
and  bottles  are  laid  down  the  middle.  Instead  of  tucking  the  bed-coverings  in 
all  around,  they  should  be  folded  back  to  the  edge  of  the  mattress  on  one  side, 
in  order  to  put  the  patient  to  bed  with  the  least  possible  loss  of  heat  and  dis- 
turbance of  the  covers.  When  put  to  bed,  hot-water  bottles  or  cans  are  placed 
down  the  sides,  at  the  feet,  and  under  the  arms,  with  a  single  blanket  between 
them  and  the  patient,  where  they  remain  until  reaction  sets  in.  They  must  be 
watched  with  extreme  care  on  account  of  the  great  danger  of  producing  a  serious 
burn.  From  neglect  of  this  precaution  I  have  seen  three  ovariotomy  patients 
with  extensive  sloughs  about  the  hips,  and  one  woman  with  a  bad  burn  on  the 
heel  invaliding  her  for  two  years.  In  my  first  ovariotomy,  a  densely  adherent 
tumor  weighing  116  pounds,  the  only  serious  drawback  in  the  convalescence  was 
an  extensive  deep  water-bag  burn  on  the  right  thigh. 

The  room  should  be  darkened  and  the  patient  left  in  exclusive  charge  of  her 

44 


POSITIO]Sr   IX   BED.  45 

nurse,  who  should  under  no  circumstances  leave  her  alone  for  a  minute.  I  have 
often  known  women  to  get  out  of  bed,  while  only  semi-conscious,  either  in  eager 
desire  to  allay  their  thirst  or  to  find  morphin.  After  one  of  my  earliest  abdomi- 
nal hysteromyomectomies,  the  patient,  an  old  Irish  woman,  got  out  of  bed  and 
walked  through  two  rooms  and  over  a  brick  pavement  to  the  closet  in  the  yard. 
Another  patient,  a  mulatto  girl  who  had  an  extensive  suppurative  peritonitis, 
persisted  in  getting  out  of  bed  and  lying  upon  the  floor,  never  having  slept  in 
a  bed  in  her  life  before.  Both  of  these  cases  recovered.  Perfect  quiet  must 
be  the  rule  throughout.  The  advantage  of  utilizing  the  convalescence  as  an 
enforced  rest  cure  can  not  be  ovestimated.  By  this  means  the  wear  and  tear  of 
years  of  suffering  upon  the  health  will  sometimes  largely  be  made  up  within  a 
few  weeks.  Restraint  umst  be  exercised  while  the  effects  of  the  anesthesia  are 
passing  off  only  to  the  extent  of  preventing  the  patient  from  falling  out  of  bed 
or  tossing  continually  to  and  fro. 

Position  in  Bed  . — It  is  not  necessary,  however,  for  her  to  remain  per- 
sistently on  her  back  for  the  first  week ;  on  the  contrary,  she  may  be  carefully 
turned  from  one  side  to  the  other  after  the  effect  of  the  anesthesia  has  passed  off, 
if  the  change  makes  her  more  comfortable.  It  is  best  to  avoid  frequent  turning, 
especially  of  nervous  patients,  who  will  not  be  comfortable  long  in  any  one 
position.  If  the  patient  becomes  very  weary  after  four  or  five  days,  she  may 
even  be  picked  u^)  by  four  assistants  catching  the  corners  of  the  sheet  and  lifted 
onto  a  cot,  while  her  own  bed  is  aired,  changed,  and  shaken  up. 

Bandage . — After  the  first  dressings  ai-e  removed  a  small  piece  of  gauze 
should  be  strapped  by  adhesive  plaster  over  the  incision  and  renewed  daily  for 
two  months.  The  value  of  abdominal  bandages  to  prevent  hernise  has  been 
greatly  overestimated.  I  advise  their  use  only  in  fat  women,  or  where  the  ab- 
dominal wall  is  exceedingly  lax  and  the  muscles  atrophic  ;  in  all  other  cases  they 
can  be  dispensed  with,  unless  the  patient  feels  more  comfortable  with  one  on. 
Where  they  are  necessary  they  should  be  worn  from  six  months  to  a  year. 

The  permanent  buried  sutures  give  all  the  support  to  the  incision  that  is 
required. 

Toilet . — The  personal  care  of  the  patient  devolving  upon  the  nurse  is  so 
important  that  I  add  a  few  directions  about  cleanliness  and  toilet. 

As  soon  as  consciousness  returns  the  hands  and  face  are  bathed  in  cool  water 
and  the  mouth  cleansed  with  a  gauze  sponge  dipped  in  ice  water.  If  there  is  a 
tendency  to  choke  up  with  nuicus,  the  fauces  must  be  wiped  out  with  a  clean 
napkin  away  back  in  the  throat.  After  the  patient  is  able,  a  gargle  of  hot  water 
relieves  the  thirst  and  the  unpleasant  taste  of  ether  in  the  mouth. 

The  head  must  be  kept  low,  without  a  ])illo\v  at  first,  to  assist  breathing  and 
to  lessen  the  nausea.  A  hair  pillow  under  the  flexed  knees  gives  a  more  com- 
fortable position. 

Bathing. — The  morning  after  the  operation  the  patient  may  be  given  an 
alcohol  bath — one  part  alcohol  and  three  parts  water — at  a  temperature  of  120°  F. 
Beginning  with  face  and  arms,  carefully  placing  towels  under  the  parts  so  as  not 
to  wet  the  bed,  and  exposing  small  portions  at  a  time,  the  whole  body  may  be 


46  CARE    OF   WOUND    AND    PATIENT   UP   TO    RECOVERY. 

washed  with  a  soft  gauze  cloth.  The  alcohol  bath  should  be  given  during  the 
first  forty-eight  hours,  after  which  the  regular  daily  bath  of  warm  water  and 
soap  may  be  resumed.  The  abdominal  bandage  must  not  be  removed  until 
the  surgeon  orders  it  done,  after  which  a  fresh  bandage  should  be  put  on  night 
and  morning. 

The  nightdresses  should  be  made  open  in  the  back,  to  be  worn  like  a  pina- 
fore, and  a  clean  one  morning  and  evening  adds  greatly  to  the  patient's  com- 
fort. The  hair  should  be  kept  neatly  braided  in  two  braids,  and  the  mouth 
cleansed  several  times  a  day. 

The  bed  should  be  changed  every  morning,  except  the  bottom  sheet,  which 
may  remain  on  for  four  days.  The  draw  sheet  should  be  changed  every  night 
and  morning  with  the  patient's  undershirt. 

The  room  should  be  always  neat  and  tidy  ;  things  should  have  a  place  and  be 
kept  in  it,  all  unnecessary  articles  and  ornaments  having  been  removed.  Every 
article  must  be  dusted  with  a  damp  cloth  each  morning. 

Sedatives  . — If  the  patient  is  tired  and  restless,  a  tepid  sponge  bath,  fol- 
lowed by  gentle  rubbing  and  a  cup  of  hot  cocoa  (not  too  strong),  will  often  take 
the  place  of  a  narcotic. 

If  there  is  much  pain  after  the  operation,  a  hypodermic  injection  of  one 
eighth  or  one  fourth  of  a  grain  of  morphin  may  be  given,  when  consciousness 
has  fully  returned,  and  the  dose  should  be  repeated  if  sleep  during  the  first  night 
can  not  be  secured  without  it.  Milder  sedatives  are  useless,  but  the  morphin 
must  not  be  continued  longer  than  thirty-six  to  forty-eight  hours.  Morphin 
must  be  used  with  greater  caution  when  the  woman  is  hysterical.  Indeed,  it  is 
often  better  to  allow  an  hysterical  woman  to  suffer  than  to  use  it  at  all. 

I  know  that  the  medical  profession  is  divided  on  the  question  of  using 
morphin  after  abdominal  operations,  some  able  physicians  objecting  strongly  to 
its  use,  while  not  a  few  surgeons  still  venture  to  assert  its  necessity.  I  have  no 
hesitation  in  declaring  myself  emphatically  in  favor  of  hypodermics  of  morphin 
during  the  first  twenty-four  hours,  in  all  cases  of  severe  suffering,  under  the 
limitations  I  have  just  indicated. 

Violent  movements  should  be  controlled  as  far  as  possible  by  moral  suasion 
with  efforts  at  gentle  i-estraint.  Under  no  circumstances  should  a  woman,  semi- 
conscious and  writhing  in  pain,  be  pinned  down  to  the  bed  by  force,  as  I  have 
sometimes  seen.  She  is  far  more  liable  to  do  herself  injury  in  this  way  than  if 
left  uncontrolled. 

IS^ausea. — The  nausea  from  the  anesthetic  is  variable,  being  most  pro- 
nounced after  long  operations  ;  it  usually  ceases  in  from  twenty-four  to  forty- 
eight  hours,  although  it  may  last  three  or  four  days,  or  even  a  week.  Little  or 
no  nourishment  should  be  given  at  first  while  the  vomiting  is  active.  If  the 
patient  is  weak  and  the  nausea  persists,  nutrient  rectal  enemata  of  a  small  cup- 
ful of  peptonized  milk  and  the  yolks  of  two  eggs,  with  salt,  may  be  given  every 
six  or  eight  hours.  Nausea  will  often  be  relieved  by  teaspoonfuls  of  very  hot 
water,  or  a  drop  or  two  of  tincture  of  capsicum  in  water,  or  a  quarter  of  a  drop 
of  creosote  in  a  teaspoonful  of  limewater.     A  mustard  plaster  over  the  pit  of 


DIET   LISTS.  47 

the  stomacli  often  helps.  The  treatment  of  severe  forms  of  vomiting  bj  wash- 
ing out  the  stomach  is  discussed  in  Chapter  XXII. 

Food . — The  first  food  given  should  be  a  teaspoonf ul  of  milk  or  hot  weak 
tea,  at  half-hour  intervals,  increasing  the  quantity  as  the  stomach  becomes  toler- 
ant ;  limewater  may  be  added  to  the  milk.  Strong  cofFee  is  also  occasionally 
valuable  as  a  stimulant. 

Egg  albumen  is  a  tasteless  and  most  nutritious  food.  It  is  prepared  by  beat- 
ing up  the  whites  of  four  eggs  into  a  liquid  froth,  and  allowing  it  to  stand  in  a 
cool  place  for  an  hour  or  more,  when  about  50  cubic  centimeters  (about  2  ounces) 
of  liquid  albumen  may  be  drained  off,  leaving  the  frothy  part  behind.  Another 
way  of  preparing  albumen  is  to  pour  the  white  of  one  egg  over  half  a  glass  of 
finely  crushed  ice ;  stir  gently,  and  add  a  little  sugar  and  lemon.  Egg  albumen 
should  be  made  fresh  every  six  to  twelve  hours,  according  to  the  time  of  year. 
It  is  best  given  a  teaspoonf  ul  or  two  at  a  time,  mixed  in  two  or  three  tablespoon- 
fuls  of  cold  water,  wnth  a  little  sugar,  with  five  or  ten  drops  of  lemon  juice ;  if 
preferred,  a  teaspoonful  of  sherry  wine  may  be  added. 

Additional  articles  of  liquid  diet  are  chicken  broth,  beef  tea,  and  the  various 
gruels.  Hot  oyster  soup,  with  the  oysters  taken  out,  is  a  valuable  and  appetizing 
addition  to  the  diet  list  when  other  liquids  have  become  tiresome.  Wine  whey 
and  clam  juice  are  occasionally  useful. 

From  120  to  250  cubic  centimeters  (4  to  8  ounces)  of  nourishment  will  be 
taken  in  this  way  m  the  second  twenty-four  hours,  increased  to  300  or  400  cubic 
centimeters  (10  to  13  ounces)  in  the  third. 

From  the  third  or  fourth  to  the  seventh  day,  if  all  is  going  well,  soft  diet 
may  be  given.  This  consists  of  soft-boiled  eggs,  milk  toast,  bread,  soups,  cus- 
tards and  jellies,  with  milk  punch  or  eggnog.  After  the  first  week  stronger 
diet  may  be  gradually  resumed. 

As  the  widest  divergence  of  opinion  may  and  does  exist  as  to  what  a  liquid 
or  soft  diet  is,  I  add  here  a  diet  list  prepared  by  an  experienced  nurse  in  my 
private  sanatorium : 

DIET  LISTS. 
Liquid  Food  : 

Milk.— Plain,  peptonized,  sterilized,  malted;  with  albumen,  milk  punch,  eggnog, 
koumiss. 

TFtnes.— Grape  juice  (unfermented),  cocoa  cordial,  wine  whey,  inullcd  wine,  sherry- 
whip. 

B)'ofhs.—Beei  tea,  beef  broth,  broiled  beef  essence,  chicken  brotli,  oyster  broth,  clam 
broth,  soiuatose. 

Soups.— Mock  bisque,  tomato,  cream  of  rice,  cream  of  asparagus,  cream  of  pea,  con- 
somme, bouillon. 
Soft  Foods : 

Eggs. — Poached,  shirred,  soft-boiled. 

Jellies. — Wine,  orange,  or  coffee  jelly. 

Crea»i.s.— Apple  float ;  whipi)ed,  t)raugo,  or  Spanish  cream  ;  cream  of  tapioca,  cream 
of  rice ;  baked  custard  in  cups,  boiled  custard  with  float,  tapioca  Avith  baked  apples, 
arrowroot  blanc  mange,  orange  sherbet,  lemon  sherbet,  junket  (plain,  or  made  with 
wine),  panada. 


48  CARE    OF    WOUND    AND    PATIENT    UP   TO    RECOVERY. 

SPECIAL  DIETS. 

Oijsters  and  Sweetbreads. — Creamed  oysters,  broiled  oysters,  oysters  on  the  half 
shell ;  creamed  sweetbreads,  broiled  sweetbreads. 
Eggs. — Poached,  shirred,  soft-boiled. 
Beef. — Scraped  beef  sandwiches. 

Birds. — Partridges  (broiled  or  roasted),  broiled  squab,  chicken  stewed  with  rice. 
Porridge. — Wheat  flakes,  oatmeal  (strained). 

Thirst. — The  thirst  for  the  first  twelve  hours  after  abdominal  section  is 
sometimes  overpowering,  and  the  patient  in  her  desire  to  allay  it  scarcely 
knows  what  she  is  doing.  One  of  my  patients,  a  desperate  ovariotomy  case, 
reached  down  to  her  feet  and  pulled  up  the  hot  water  bag,  from  which  she 
drank  at  least  a  quart  of  warm  water.  Another,  a  colored  girl,  with  general 
suppurative  peritonitis,  and  with  a  drainage-tube  in  the  abdomen,  got  out  of 
bed,  walked  into  the  hall,  and  drank  a  large  quantity  of  water  from  the  spigot 
of  the  water  cooler ;  neither  of  them  w^ere  apparently  hurt  by  their  expe- 
riences. 

Of  the  minor  complications  following  abdominal  oj)erations,  thirst  is  the 
commonest,  and  is  often  exceedingly  distressing. 

The  best  way  to  treat  thirst  in  all  cases  is  to  meet  it  as  far  as  possible  pre- 
ventively by  giving  the  patient  a  rectal  enema  of  one  liter  (quart)  of  normal 
saline  solution,  while  she  is  still  on  the  operating  table,  at  the  conclusion  of  the 
operation.     This  is  done  with  the  table  elevated  six  to  eight  inches. 

Dr.  Clark  has  recently  reviewed  the  results  of  the  use  of  the  saline  enemata 
in  this  way  in  my  clinic  for  the  past  two  years.  I  quote  from  his  article. 
{Ame?\  Jour,  of  Obst.,  vol.  xxxiv,  No.  2.) 

In  order  that  the  patient  may  retain  the  enema  she  must  be  under 
the  anesthetic  when  it  is  given,  otherwise  the  bowel  will  not  toler- 
ate such  a  large  quantity  of  liquid.  For  this  reason  it  is  impossible  to  give 
liquids  in  sufficient  quantities  in  the  conscious  subject  to  be  of  any  great  service 
in  assuaging  the  thirst. 

A  stiff  rectal  tube  is  inserted  well  up  into  the  sigmoid  flexure,  and  the  fluid 
slowly  poured  into  a  glass  funnel,  held  three  feet  above  the  level  of  the  patient's 
buttocks.  In  this  posture  the  solution  gravitates  down  into  the  sigmoid  flexure 
and  the  descending  colon,  and  is  rarely  expelled,  even  in  the  most  violent  attacks 
of  retching  and  vomiting  during  the  recovery  from  the  anesthesia. 

By  comparing  the  charts  of  one  hundred  abdominal -section  cases  which 
have  not  had  the  enemata,  with  another  hundred  cases  which  had  them,  a  re- 
markable alleviation  of  thirst  was  noted,  as  well  as  a  reduction  in  the  amount  of 
the  vesical  irritability,  which  is  so  common  in  operative  cases. 

One  or  two  months  after  the  adoption  of  this  plan  of  using  the  thirst  ene- 
mata the  head  nurses  in  the  gynecological  wards,  who  had  not  been  told  of 
the  treatment,  began  spontaneously  to  report  a  remarkable  improvement  in  the 
intense  thirst  usually  experienced. 

In  one  hundred  charts  taken  at  random  from  our  history  files  since,  there 


IRRITABILITY    OF   THE    BLADDER    AND    DECREASE    IN    URINARY    EXCRETION.      49 

is  rarely  any  note  about  thirst,  and  the  patients  often  passed  the  first  twenty-four 
hours  without  even  asking  for  water. 

Irritability  of  the  Bladder  and  Decrease  in  Urinarv  Ex- 
cretion.— Since  the  opening  of  the  gynecological  dej)artment  of  the  Johns 
Hopkins  Hospital,  a  careful  urinary  record  has  been  kept  of  each  case  subse- 
quent to  abdominal  section. 

The  temporary  partial  suppression  of  urine  for  the  first  four  or  five  days 
after  an  abdominal  section  is  frequently  so  marked  as  to  give  rise  to  a  fear  of 
the  possibility  of  some  grave  renal  disturbance. 

In  a  paper  by  Dr.  ^Y.  AV.  Russell  {Johns  Hopli.  Hosj).  Bej).,  1894),  after  a 
careful  review  of  the  urinary  charts  of  many  cases,  the  conclusion  was  reached 
that  the  frequency  of  vesical  iriitability  in  post-operative  cases  was  due  to  the 
retention  of  small  quantities  of  highly  concentrated  urine  in  the  bladder.  This 
theory  is  unquestionably  correct,  for  a  notable  increase  in  the  amount  of  urine 
excreted  after  the  saline  enemata  has  l)een  followed  by  a  marked  decrease  in 
the  frequency  of  catheterization  and  in  vesical  irritability,  and  consequently 
post-operative  cystitis  or  vesical  irritability  now  rarely  occurs : 

A  comparison  by  Dr.  Clark  of  a  series  of  one  hundred  cases  without  saline 
enemata,  with  a  senes  of  one  hundred  cases  with  them,  show  these  interesting 
points  : 

"  The  natural  result  of  almost  doubling  the  watery  constituent  of  the  urine 
is  to  decrease  the  specific  gravity.  The  specific  gravity  of  cases  in  which  the 
enemata  are  not  given  ranges  between  1025  and  1030,  while  those  with  it 
show  a  reduction  to  an  average  of  1021. 

"  The  physical  characteristics  of  the  urine  in  the  two  series  are  also  markedly 
different.  As  would  be  expected,  the  urine  with  high  specific  gravity  is  of  a 
reddish-brown  color,  at  times  almost  suggesting  hemoglobinuria,  and  after  stand- 
ing deposits  a  heavy  stratum  of  reddish  sediment,  consisting  largely  of  the  phos- 
phatic  salts  and  urates.  The  urine  of  the  cases  in  which  the  saline  solution  is 
given  usually  presents  a  normal  color,  and  wliere  more  than  900  cubic  centi- 
meters are  voided  in  the  first  twenty-four  hours  it  may  even  have  the  clear, 
limpid  appearance  of  a  urine  deficient  in  solid  constituents. 

"  The  average  daily  quantity  of  urine  excreted  for  the  first  seven  days  after 
operation,  in  the  two  series  of  cases,  is  as  follows : 


With  Saline  Enemata. 

First  day 752  cubic  ceiitimeters. 

Second  day G20      "  " 

Third  day (505      •• 

P'ourth  day 6:55      '• 

Fiftii  day 595      " 

Sixth  day 672      '• 

Seventh  dav 640      " 


WiTHoiT  Saline  Enemata. 

First  day 481  cubic  centiuietors. 

Second  day 505      " 

Third  day 498     " 

Fourth  day 550      " 

Fifth  day 654     " 

Sixtli  (hiy 656 

Seventh  dav 591      " 


"  The  daily  excretion  of  urine  in  gynecological  cases  when  they  arc  admitted 
into  the  wards  is  below  the  normal  (1,200  to  1,500  cubic  centimeters),  rarely 
being  higher  than  1,100  cubic  centimeters. 


44 


60 


CARE    OF    WOUND    AND    PATIENT    UP   TO    RECOVERY. 


"  The  average  quantity  in  fifty  cases  wliich  I  have  had  carefully  measured  is 
1,000  cubic  centimeters.  In  constructing  the  accompanying  composite  urinary 
chart  I  have  assumed  this  quantity,  to  be  the  normal.  This  chart  brings  out  a 
number  of  interesting  points.  In  following  the  two  lines  as  they  descend  from 
the  initial  line,  the  wide  difference  in  the  amount  excreted  by  the  cases  with  and 
without  the  enemata  is  seen  at  a  glance. 


Composite  Urinary  Chart  of  One  Hundred  Cases  with  and  without  Saline  Enemeta 


The  broken  line  is  the  composite  of  100  cases  treated  by  saline  enemata.  The  tinbrolven  line  is  the  com- 
posite of  100  cases  without  the  enema.  In  the  table  1,000  cubic  centimeters  is  taken  as  the  normal  amount  of 
urinary  excretion  in  twenty-four  hours.  All  the  cases  were  abdominal  sections  for  various  diseases.  The 
broken  line  represents  the  amount  of  urine  excreted  when  saline  enemata  were  used.  The  unbroken  line 
represents  the  amount  of  urine  excreted  when  the  enemata  were  not  used.  One  liter  of  the  normal  saline 
solution  composed  each  enema. 

"  The  first  series  of  one  hundred  cases  shows  an  average  of  752  cubic  centi- 
meters at  the  end  of  the  first  twenty -four  hours,  while  the  second  shows  but  481 
cubic  centimeters. 

"  The  solid  line  (cases  without  enemata)  drops  to  its  lowest  point  on  the  first 
day,  and  for  three  days  does  not  rise  much  above  the  point,  while  the  broken 
line  (cases  with  enemata)  shows  a  greater  excretion  the  first  day  than  for  seven 
subsequent  days.  It  is  not  until  the  end  of  the  fifth  day  that  the  excretion  in 
the  two  series  of  cases  is  of  equal  amount. 

"  A  further  study  of  this  composite  chart  reveals  other  interesting  points. 
In  both  series  of  cases  the  least  amount  of  urine  is  excreted  during  the  third 
day  (605  cubic  centimeters  in  one,  498  cubic  centimeters  in  the  other),  wdiich  is 
readily  accounted  for  by  the  fact  that  it  is  the  routine  practice  to  administer  a 
saline  purgative  on  the  evening  of  the  second  day,  which  usually  acts  on  the 
third  day.  The  diminution  is  therefore  a  normal  physiological  one,  due  to  the 
hydragogue  action  of  the  purgative. 

"  Soft  diet  is  begun  on  the  fifth  and  sixth  days,  and  as  a  result  there  is  an- 
other drop  in  the  two  lines,  as  the  patient  then  begins  to  take  more  of  soft  than 
of  liquid  diet.  At  the  end  of  the  fifth  day  the  excretion  in  both  series  of 
cases  is  equal,  and  from  this  time  the  two  lines  ti-avel  together  until  they  again 
reach  the  normal  base  line  on  the  twelfth  to  thirteenth  day. 


CATHETER. 


51 


"  There  appears  to  be  a  further  explanation  for  the  greater  excretion  of  urine 
in  the  cases  which  have  the  saline  enemata  than  that  it  is  merely  due  to  an  in- 
crease in  the  amount  of  water  taken  into  the  system.  The  nausea  and  vomiting- 
following  anesthesia  usually  disappears  by  the  end  of  the  first  twenty-four 
hours,  after  which  the  imbibition  of  water  has  not  been  restricted  in  either 
series. 

"  Notwithstanding  the  fact  that  in  both  series  of  cases  about  the  same  quan- 
tity of  water  is  taken  by  the  mouth,  the  excretion  in  one  remains  very  low  for 
three  days,  at  no  time  being  above  505  cubic  centimeters,  while  the  other  shows 
not  less  than  GOO  cubic  centimeters,  or  over  100  cubic  centimeters  more  urine 
passed  daily  by  the  patients  who  have  had  the  enemata.  From  this  observation 
it  would  appear  that  the  persistent  renal  torpidity  is  due  to  the  irritant  or  toxic 
etfects  of  the  greatly  concentrated  urine,  and  by  supplying  the  body  with  a  liter 
of  salt  solution  this  partial  suppression  is  to  a  great  extent  prevented,  and  the 
kidney  at  once  resumes  its  normal  function  as  soon  as  the  patient  begins  to  take 
water. 

"  The  accompanying  table  of  two  series  of  fifty  cases,  with  the  record  of  the 
daily  excretion  in  each  individual  case,  emphasizes  the  fact  which  the  composite 
chart  brings  out. 

"  In  thirty-five  of  the  fifty  cases  with  the  enemata  the  excretion  during  the 
first  twenty -four  hours  was  greater  than  it  was  on  the  seventh  day  after  opera- 
tion, while  in  forty  cases  without  enemata  the  excretion  was  less  during  the  first 
day  than  during  the  seventh,  the  figures  in  the  former  being  almost  exactly  re- 
versed in  the  latter.  The  following  table,  taken  from  these  two  series  of  cases, 
also  shows  the  same  result : 


Urine  excreted. 

With  enemata. 

Without  enemata. 

1,000  cubic  centimeter 

3  or  over 

Cases. 

7 
5 
3 
12 
9 

n 

2 
1 

Cases. 

1 

900     " 

800     " 

1 

700     " 

H             .i 

2 

600     " 
500     " 

::  :: 

7 
8 

400     " 

1.  u 

14 

300     " 
200     " 

15 
2 

100     " 

Total 

50 

50 

Catheter . — The  catheter  should  only  be  used  to  draw  the  urine,  if  the 
patient  is  unable  to  pass  it  naturally  after  six  or  eight  hours,  and  then  the  ut- 
most care  must  be  taken  to  pass  a  clean  catheter,  through  a  clean  urethral  orifice, 
under  inspection.  If  the  catheter  has  to  be  used  at  all,  its  use  must  be  discon- 
tinued as  soon  as  })ossil)le.  If  vesical  irritability  is  ])ersistent,  it  will  improve 
upon  taking  sj)irits  of  nitrous  ether,  twenty  to  thirty  drops,  every  two  lK»urs,  or 
five  drops  of  copaiba  in  capsules  three  times  a  day. 

Bowels. — I  have  often  noticed  that  surgeons  grow  too  anxious,  and  work 


52  CARE   OF    WOUXD    AND    PATIENT    UP   TO    RECOVERY. 

too  hard  to  get  the  howels  moved  for  the  first  time.  If  the  patient  is  doing 
well  in  other  ways,  it  need  cause  no  worry  should  the  bowels  be  sluggish  and  not 
respond  until  as  late  as  the  fifth  or  sixth  day.  Often  after  two  or  three  days  of 
active  efforts,  if  the  patient  is  left  quite  alone  they  move  spontaneously  in  six  or 
eight  hours. 

As  a  routine  line  of  treatment,  I  give  on  the  evening  of  the  second  day 
somethino^  which  will  move  the  bowels  on  the  followino-  mornino-.  Calomel  will 
be  found  to  be  the  most  efticacious,  and  is  as  a  rule  best  borne  by  the  patient. 
It  can  be  given  in  one  dose  of  two  or  three  grains,  or  one  quarter  to  one  sixth 
of  a  grain  may  be  given  every  hour  until  the  same  amount  is  reached,  fol- 
lowed in  the  morning  by  six  to  eight  ounces  of  a  solution  of  citrate  of  magnesia. 
About  two  hours  later  an  enema  of  100  cubic  centimeters  of  olive  oil  with  30 
cubic  centimeters  of  glycerin  should  be  injected  as  high  as  possible  into  the  rec- 
tum. If  this  is  not  effective,  four  to  six  liours  may  be  allowed  to  elapse  before 
another  attempt  is  made  with  an  injection,  consisting  of  a  pint  of  water  at  a  tem- 
perature of  110°  F.  and  soapsuds. 

A  satisfactory  saline  enema  much  used  by  Dr.  C.  P.  Noble  is  the  following 
concentrated  solution  of  the  sulphate  of  magnesia  : 

J^  Magnes.  sulph 3  ij ; 

01.  terebinth 3  ss. ; 

Glycerinse 3  j ; 

Aquse q.  s.  ad  3  iv. 

M.  and  inject  in  bowel. 

It  is  not  advisable  to  use  more  than  three  enemata  during  the  third  day  ;  it  is 
better  to  assist  the  calomel  by  castor  oil  or  magnesium  sulphate  in  half-ounce 
doses,  or  by  a  pill  of  aloin,  strychnin,  and  belladonna. 

When  the  bowels  are  once  opened,  they  should  be  kept  open  by  a  movement 
at  least  every  other  day. 

Tympany,  which  often  occasions  much  distress,  is  usually  sjDcedily  relieved 
by  the  free  evacuation  of  the  bowels.  Drop  doses  of  tincture  of  capsicum,  or 
a  few  drops  of  tincture  of  nux  vomica  in  a  teaspoonful  of  hot  pepper  tea,  are 
valuable  adjuvants.  A  rectal  enema  of  90  cubic  centimeters  (3  ounces)  of  milk 
of  asafetida  will  also  often  relieve  it. 

Temperature  . — The  temperature  must  always  be  carefully  watched.  On 
the  second  or  third  day  it  is  commonly  elevated  to  100°  F.,  or  even  101°  F. 
(37*8°  or  38'3°  C),  but  it  usually  drops  with  the  first  free  movement  of  the  bowels. 
This  slight  rise  in  temperature  appears  to  be  due  to  the  absorption  of  a  fibrin 
ferment,  and  it  may  in  exceptional  cases  be  prolonged  for  several  days  beyond 
the  usual  period.  A  persistent  temperature,  however,  above  100°  is  in  most 
cases  due  to  infection  either  of  the  wound  or  in  the  peritoneum.  A  sudden 
rise  in  temperature,  sometimes  attended  with  chill,  toward  the  end  of  the  first 
week,  is  often  the  first  indication  of  suppuration  in  the  abdominal  wall.  The 
wound  should  be  inspected  immediately  for  any  hard,  red,  tender  areas  on  one 
side  or  the  other,  the  stitch  or  stitches  at  that  point  removed,  and  the  lips  of  the 


PULSE.  53 

incision  slightly  separated,  to  favor  the  discharge  of  pus.  "When  the  pns  has 
escaped,  the  temperature  falls  at  once. 

A  chart  showing  the  composite  temperature  in  ten  normal  cases  for  the  lirst 
week  is  here  given  (see  Figs.  322-325,  p.  54). 

Pulse . — The  pulse  is  likely  to  remain  quickened  20  or  30  beats  or  more 
for  three  or  four  days  after  any  severe  operation.  If  the  general  condition  is 
good,  and  the  pulse  full  and  compressible,  this  need  cause  no  anxiety.  The  nor- 
mal course  is  a  steadily  falling  pulse  after  operation,  falling  less  rapidly  if  there 
is  much  pain.  A  falling  pulse  is  a  good  sign  ;  a  rising  pulse  always  calls  for  in- 
vestigation. In  general  a  pulse  from  120  to  130  beats  needs  watching ;  a  pulse 
of  140  beats  needs  closer  watching ;  a  pulse  of  150  beats  needs  anxious  watch- 
ing ;  a  pulse  of  160  beats  does  not  as  a  rule  recover  unless  it  begins  to  fall 
within  six  to  twelve  hours  after  the  operation.  Neither  the  temperature  nor 
the  pulse,  however,  should  be  studied  alone,  but  always  in  association.  If  the 
pulse  is  high,  from  120  to  140  beats,  combined  with  a  high  temperature  after 
the  first  day,  when  the  bowels  have  been  freely  moved,  infection  has  probably 
taken  place.  The  most  satisfactory  sign  of  progress  is  a  free  evacuation  of  the 
bowels,  with  pulse  and  temperature  dropping  together. 

Facial  Expression . — Facial  expression  is  a  sign  scarcely  less  signifi- 
cant than  the  temperature  and  pulse,  and  taken  together  with  these  forms  a  good 
index  of  the  general  condition.  A  bright  natural  expression  is  to  be  looked  for 
during  the  normal  convalescence;  a  flushed,  dusky,  anxious,  haggard,  or  a 
lack-luster  look  are  indicative  of  complications. 

Wound . — Unless  some  special  cause  arises,  the  wound  need  not  be 
dressed  until  the  tenth  day,  when  fresh  gauze  and  cotton  dressings  should 
be  put  on  with  the  dressing  forceps.  The  bandage  may  be  changed  daily, 
and  the  back  Avell  rubbed  ^vith  a  solution  of  alcohol  and  water,  half  and  half. 
Boric  acid  and  bismuth  powder  are  also  good  to  rub  into  the  back.  This 
rubbing  is  the  best  we  can  do  for  the  severe  pain  so  constantly  felt  in  the 
back. 

Sutures. — The  use  of  the  permanent  buried  silver-wire  suture  and  subcu- 
itcular  catgut  sutures  has  relieved  the  patients  of  considerable  anxiety,  for  often 
the  removal  of  sutures  was  looked  forward  to  with  great  dread.  The  abdominal 
dressings  need  riot  be  disturbed  until  the  tenth  day  except  in  case  of  wound  in- 
fection. They  should  be  carefully  lifted  off  and  rejilaced  by  several  layers  of 
fresh  sterilized  gauze.  If  they  have  become  adherent  to  the  incision  a  little 
sterilized  water  poured  on  will  rapidly  loosen  them.  The  skin  about  the  inci- 
sion should  not  be  cleansed  until  about  the  fourteenth  day.  Pledgets  of  cotton 
wet  with  dilute  alcohol  are  best  for  this  purpose. 

The  catgut  sterilized  by  the  cumol  method  is  usually  absorbed  by  the  eighth 
to  the  tenth  day.  Interrupted  sutures  are  removed  on  the  tenth  day.  First 
expose  the  loop  by  pulling  up  the  suture  a  little  with  forceps,  then  cut  it  close  to 
the  skin,  and  draw  it  out  toward  the  side  on  which  it  is  cut,  to  avoid  pulling  the 
edges  of  the  wound  apart.  Adhesive  straps  across  the  wound  after  removing 
the  sutures  are  not  necessary.     If  the  bandage  is  kept  well  in  place,  and  put 


54 


CAKE    OF    WOUXD   AND    PATIEXT    UP   TO    RECOVERY. 


DAY   OF 
OPERATION 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

90 

UJ 

:3  80 

Q. 

70 

UJ       99° 

1- 

<                o 

CC       98 

UJ 

a. 

UJ                o 

1-       97 

^ 

— 

A 

V     / 

/N 

SUSPENS 

lO  UTERI 

•v^ 

■>t 

V 

V 

V 

^  V 

\/ 

r 

\. 

y^ 

\ 

A 

A 

V 

A 

^      X<| 

V 

v^ 

""•%/ 

;^V'- 

\ 

A^      / 

r^ 

>^    \ 

/ 
/ 

• 

Fig.  3:i2. 


UJ 

(n 

-J 

Ql 

90 
80 
70 

UI 

Zi 

< 

UJ 
Ql 

UJ 

99° 
98° 
97° 

V 

A 

^ 

^ 

-■ 

( 

■ 
:ys 

rEC 

1 — 

TO 

VIY 

(Sir 

iple 

A 

) 

\ 

/  ^ 

V 

\ 

— », 

_A 

V- 

^ 

V' 

y 

V 

^ 

V 

— 

V 

/     ^ 

\^J 

■'*\ 

\^' 

y^. 

V 

> 

\- 

r  ■■--.,.^. 

V 

.^^ 

V 

('      ">. 

Fig.  323. 


100 

UJ 

§      90 

D. 

80 

UJ     100° 
cc 

1- 

<               o 

q:       99 

UI 

Q. 

UJ                o 

t-       98 

■ 

-A^ 

HV 

ST 

IRQ 

-  M 

YO 

/lEC 

TO 

VIY 

V 

r 

—  • 

>-• 

^ 

^ 

. 

v_ 

/ 

^>r' 

""^• 

■^.-' 

,.^- 

'^ 

<::^ 

-s 

s. 

'>v ' 

■<;r~ 

Fig.  324. 


100 
90 

UI 

en 

_i 

°-      80 
70 

100° 

UJ 

oc 

^       99° 

< 

o: 

UJ 

Q.               o 

2      98 

u 

1- 

97° 

A 

HV 

STl 

( 

■ 
For 

-s/ 

Pe 

.LP 

VIC 

NG 

Infl 

1 .. 

3-90P 

immato 

■y  C 

?EC 

isea 

TO 

se.) 

VIY 

^ 

-• 

A 

A 

> 

V. 

^, 

A^ 

A 

/ 

f\ 

\  y 

A 

/V 

/ 

V 

;C' 

< 

V 

V 

V 

,\ 

V 

— N 

s 

/ 

rx^ 

> 

\ 

A. 

V 

v_ 

V 

V 

>. 

-Temperature        Pulse  Fiu.  3:i 


Figs.  3'2'2,  323,  324,  325,  showing  the  Avekage  Charts  or  Composite  Temperatires  and  Pulse  Eates 

IN  Ten  Cases  in  each  Group. 

Cases  were  selected  which  appeared  to  run  a  smooth  course  to  recovery  •  these  were  averaged,  and  the 
temperature  and  pulse  rates  then  tabulated,  as  shown.  (See  Jo?ins  Hopk.  Hosp.  Rep.,  1890,  vol.  ii,  Nos.  3 
and  4,  p.  177.) 


COXVALESCEXCE.  55 

on  sniiglj  every  time,  the  wound  surfaces  will  naturally  remain  in  close  ap- 
proximation. 

In  ten  or  twelve  days  usually  the  patient  may  be  propped  up  with  pillows 
or  on  a  bed  rest,  and  in  from  seventeen  to  twenty-one  days,  according  to  the 
rapidity  with  which  strength  is  regained,  she  may  spend  part  of  the  time  in  a 
reclining  chair  or  on  a  sofa.  Throughout  the  convalescence  she  must  avoid 
straining  the  abdominal  nmscles,  AYhile  still  abed  she  must  not  raise  herself  to 
a  sitting  posture  or  change  her  position  witliout  aid.  Later  she  must  not  stoop 
or  lift  heavy  weights.  During  active  vomiting  the  least  strained  position  is 
lying  on  the  side  with  the  body  slightly  flexed,  or  on  the  back  with  the  knees 
drawn  up  resting  on  a  pillow.  At  the  end  of  the  fourth  or  fifth  week  she 
should  be  able  to  walk  around,  and  perhaps  go  down  stairs.  All  bodily  move- 
ments should  be  gentle  at  fij-st.  The  patient  must  not  sit  up  long  enough  at 
first  to  grow  tired  of  the  newness  of  it,  and  later  on  she  should  avoid  tiring 
herself  on  her  feet.  It  is  best  not  to  hasten  the  getting  out  of  bed,  as  a  pro- 
longed absolute  rest  is  an  important  element  in  securing  complete  restoration  to 
health.     Heavy  work  and  exhaustive  exercise  of  all  kinds  must  be  avoided. 

The  convalescence  is  by  no  means  at  an  end  when  the  patient  is  able  to  re- 
turn to  her  home. 

Disappointment  will  frequently  be  avoided  if  she  is  warned  of  this  before- 
hand, and  kept  under  obser^'ation  for  a  year  or  more  while  regaining  her  physi- 
cal and  nervous  balance  and  passmg  the  period  of  an}^  unpleasant  sequelae,  such 
as  flushes,  sweatings,  giddiness,  and  various  other  nervous  manifestations. 

Sometimes  some  of  the  original  discomforts  jjersist  for  some  months,  only 
disappearing  gradually,  so  that  complete  recovery  to  health  does  not  take  place 
until  after  a  year  or  a  year  and  a  half. 

Fresh  air,  rest,  diet,  and  tonic  treatment,  with  encouragement,  are  the  most 
important  aids  in  the  convalescence.  Change  of  air  and  scene  are  of  the  great- 
est value  in  bringing  about  complete  restoration  to  health. 

The  golf  field  is  the  best  form  of  moderate  exercise  I  know  of,  and  will 
prove  an  invaluable  adjuvant  as  soon  as  the  patient  is  able  to  take  a  little  active 
out-of-door  exercise. 


CHAPTER   XXII. 

COMPLICATIONS  ARISING  AFTER  ABDOMINAL  OPERATIONS. 

1.  Shock.     1.  Causes :   (a)  Anesthesia ;   (b)  loss  of  blood ;  (c)  enfeeblement  by  disease ;  (d)  pro- 

longed exposure  of  the  intestines.  2.  Symptoms.  3.  Diagnosis :  (a)  Shock  and  chloro- 
form asphyxia ;  (b)  shock  and  hemorrhage.  4.  Prognosis.  5.  Preventive  treatment :  (a) 
Preliminary  tonic  treatment;  (b)  temperature  of  operating  room;  (c)  care  of  patient  on 
the  table,  blankets,  hot- water  bottles,  protection  of  exposed  pelvic  viscera,  etc. ;  (d)  avoid- 
ance of  hemorrhage.  6.  Immediate  treatment :  (a)  Hypodermics;  (&)  stimulant  eneraata; 
(c)  external  application  of  heat ;  (d)  how  to  give  stimulants  and  nourishment ;  (e)  saline 
infusion. 

2.  Secondary  hemorrhage.     1.  Causes.     2.  How  to  avoid  hemorrhage  by  care  during  operation. 

3.  Symptoms.     4.  Operation.     5.  Saline  infusion. 

3.  Peculiarities  of  the  pulse. 

4.  Variations  in  temperature :  (1)  Subnormal  temperature  ;  (2)  elevated  temperature. 

5.  Vomiting.     1.  Treatment :  (a)  Medicines  to  settle  the  stomach ;  (b)  lavage ;   (c)  hot  and  cold 

applications  ;  (d)  foods  and  enemata. 

6.  Tympanites.     1.  Treatment:  (a)  Turpentine  stupes;  (h)  rectal  tube;  (c)  medication;  (t?)  pur- 

gation ;  (e)  Paquelin  cautery. 

7.  Excessive  pain.     1.  Sparing  use  of  sedatives. 

8.  Peritonitis.     1.  Traumatic  or  plastic  peritonitis  :  (o)  Symptoms;  (J)  treatment ;  (1)  purgation  ; 

(2)  diet ;  (3)  hot  and  cold  stupes.  2.  Post-operative  septic  peritonitis  :  (a)  Sanger's  condi- 
tions of  infection;  (1)  qualitative;  (2)  quantitative;  (3)  constitutional;  {b)  kinds  of  germs 
(two  typical  cases) ;  (c)  modes  of  origin  ;  (d)  symptoms ;  (e)  prognosis ;  (/)  diagnosis ; 
(^)  tabulated  symptoms  of  both  traumatic  and  septic  peritonitis;  (/()  treatment;  (1)  pro- 
phylaxis ;  (2)  medicines ;  (3)  operative  treatment ;  (a)  methods  of  operation  ;  (b)  indica- 
tions for  operation  ;  (c)  operation — vaginal ;  abdominal. 

9.  Fermentation  and  septic  fevers :  1.  Fermentation  fever.     2.  Septic  intoxication.     3.  Septice- 

mia.    4.  Pyemia. 

10.  Pleurisy:  1.  Causes.     2.  Symptoms.     3.  Treatment. 

11.  Pneumonia:  1.  Causes,     (rt)  Anesthetic ;  (&)  sepsis.     2.  Symptoms.     3.  Treatment. 

12.  Reus:  1.  Causes.     2.  Symptoms.     3.  Diagnosis.     4.  Treatment:  (r<)  Prophylaxis ;  (J)  enemata 

and  medicines;  (c)  operative. 

13.  Stitch-hole  abscess  and  suppuration  in  the  line  of  the  incision.     1.  Cause  of  infection.     2. 

Symptoms.     3.  Diagnosis.     4.  Treatment. 

14.  Nephritis.     1.  Relation  between  abdominal  operations  and  nephritis.     2.  Treatment. 

15.  Suppression  of  urine.     1.  Urinary  record.     2.  Differentiation  of  nephritis  and  ligation  of  one 

or  both  ureters.    3.  Treatment. 

16.  Urinary  fistula. 

17.  Fecal  fistula.     1.  Causes:  (a)  Trauma;  (5)  necrosis  from  pressure.     2.  Location  of  fistula.     3, 

Treatment. 

18.  Phlebitis:  1.  Symptoms.     2.  Treatment. 

19.  Emphysema  of  the  abdominal  wall. 

20.  Sudden  death :  1.  From  embolism.     2.  From  gas  bacillus. 

Marked  deviations  fi'om  the  course  of  normal  convalescence,  as  described 
in  Chapter  XXI,  comprise  complications  varying  in  gravity  from  tlie  simple 
functional  and  local  disorders  wliich  are  soon  relieved,  all  the  way  to  the  gi-aver 
systemic  manifestations  which  are  often  fatal. 

Every  normal  convalescence  is  attended  with  certain  minor  discomforts — as 
a  rule,  neither  excessive  nor  prolonged — and  the  patient  is  usually  fairly  easy 
by  the  third  or  the  fourth  day.     When,  however,  the  discomforts  persist  or  be- 

56 


SHOCK.  57 

come  exaggerated,  or  a  variety  of  other  untoward  phenomena  arise  either  to 
retard  recovery  or  to  threaten  Kfe,  the  convalescence  becomes  comphcated. 

Greater  skill  and  acumen  are  oftener  shown  in  the  quick  detection  of  these 
complications,  and  a  prompt  adoption  of  means  to  overcome  them,  than  in  the 
performance  of  a  difficult  operation  ;  for  this  reason  skilled  surgical  attention  is 
quite  as  important  in  the  convalescent  stage  as  during  the  operation  itself,  and 
it  is  unwise  for  the  surgeon  to  consign  the  care  of  the  case  to  other  hands  when 
it  is  in  any  way  possible  for  him  to  keep  a  direct  personal  supervision  until  com- 
plete recovery. 

Shock. — One  of  the  most  frequent  and  alarming  effects  of  an  abdominal 
operation  is  shock,  arising  from  a  profound  impression  made  on  the  nerve  cen- 
ters, and  indicating  extreme  depression  of  the  j)atient's  vital  forces.  Shock  is 
usually  observed  either  during  or  shortly  after  an  operation. 

Causes . — One  of  the  most  frequent  causes  of  shock  is  prolonged 
anesthesia.  The  administration  of  an  anesthetic  for  two  hours, for  instance, 
is  always  followed  by  depression  of  varying  degrees,  even  though  the  operation 
has  been  a  minor  one. 

Excessive  loss  of  blood  during  an  operation  upon  a  robust  or  even 
plethoric  mdividual,  or  a  moderate  hemorrhage  in  an  anemic  patient,  will 
speedily  produce  shock,  even  though  the  operation  be  of  short  duration.  I 
recall  one  case  in  which  there  was  the  most  profound  deiDression  following  a 
simple  oophorectomy  in  a  patient  who  was  extremely  anemic  before  the  opera- 
tion from  repeated  hemorrhages  due  to  internal  hemorrhoids.  Little  blood  was 
lost  during  the  operation,  and  the  duration  of  the  anesthesia  was  only  twenty- 
two  minutes  ;  but  when  she  was  removed  from  the  operating  table  the  pulse 
was  barely  percej^tibie,  respirations  were  shallow  and  jerky,  and  there  were  no 
signs  of  reacting  for  ten  hours  afterward.  In  this  case  the  slight  hemorrhage 
and  the  depressing  effects  of  the  anesthetic  acted  conjointly. 

A  constitution  already  enfeebled  by  disease  also  predis- 
poses to  shock ;  for  instance,  patients  debilitated  by  advanced  carcinoma  have 
scant  resisting  powers,  are  often  profoundly  depressed  by  the  operation,  and  re- 
cuperate slowly. 

Prolonged  exposure  of  the  intestines  and  omentum 
through  a  long  incision,  or  when  lifted  out  of  the  abdomen,  is  one  of  the  most 
prolific  causes  of  shock  through  the  rapid  radiation  of  heat,  especially  when 
there  has  been  already  considerable  hemorrhage  before  or  during  the  operation, 
as  in  the  case  of  a  ruptured  ectopic  pregnancy. 

While  any  one  of  these  causes  acting  alone  is  sufficient  to  produce  shock,  two 
or  more  or  all  of  them  acting  in  combination  induce  a  condition  of  profound 
depression  from  which  it  is  difficult  for  the  patient  to  rally.  For  example,  I 
would  cite  a  case,  of  not  infrequent  occurrence — that  of  a  large  fibroid  uterus 
with  extensive  subperitoneal  development,  with  a  history  of  repeated  hemor- 
rhages ;  by  pressure  on  the  ureters  and  interference  with  the  excretion  of  urine, 
the  tumor  has  also  brought  about  disease  of  the  kidneys.  8uch  a  patient  is 
already  greatly  weakened  by  the  loss  of  blood,  her  resisting  powers  are  lessened 


58  COMPLICATIONS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 

by  the  renal  affection,  and,  added  to  these  factors,  the  size  and  relations  of  the 
tumor  necessitate  a  long  incision,  exposing  the  intestines,  and  a  prolonged  anes- 
thesia is  necessary  to  effect  the  enucleation.  We  have  here  all  the  elements 
necessary  to  produce  shock,  and  if  we  add  to  these  an  extensive  hemorrhage 
daring  the  operation,  the  shock  may  speedily  prove  fatal. 

S  y  m  p  t  o  m  s  . — There  is  often  good  reason  to  anticipate  shock  from  the 
clinical  history  which  reveals  some  predisposing  cause,  such  as  an  enfeebled  con- 
dition of  the  patient  from  hemorrhage,  or  from  serious  organic  disease. 

Increasing  rapidity  of  pulse,  from  20  to  40  beats,  marked  pallor  and  coldness 
of  the  surface  of  the  body  during  an  operation,  demand  the  closest  attention  of 
the  anesthetizer  as  the  forerunners  of  shock.  Additional  evidence  of  prostration 
is  a  slow  recovery  from  the  anesthetic.  As  consciousness  returns,  the  patient  lies 
helpless  on  her  back,  unable  to  move,  scarcely  able  to  speak  above  a  whisper ; 
the  surface  of  the  body  is  pallid  and  bathed  in  a  cold  sweat,  the  lips  appear 
bloodless,  the  features  are  pinched,  the  eyelids  drooping,  and  the  general  appear- 
ance that  of  dissolution.  Various  associated  nervous  j^henomena,  such  as  hic- 
cough, twitching,  headache,  and  mild  delirium  may  be  present.  The  special 
senses  are  often  so  blunted,  that  the  patient  hears  and  sees  and  feels  with  diffi- 
culty. Respiration  is  feeble  and  gasping,  or  so  weak  as  barely  to  be  perceptible. 
The  temperature  is  depressed,  falling  from  one  to  two  degrees  below  normal. 
Reaction  may  not  set  in  for  hours,  notwithstanding  the  most  vigorous  stimulat- 
ing treatment,  and  then  may  be  so  gradual  as  to  be  recognized  with  difficulty. 
Occasionally  there  may  be  great  prostration  with  a  slow,  full  pulse ;  in  such  cases 
the  shock  is  usually  evanescent,  disappearing  quickly  under  appropriate  stimu- 
lants. 

Recovery  from  shock  is  indicated  by  the  general  reaction  of  all  the  vital 
functions ;  the  pulse  gradually  increases  in  strength  and  becomes  more  regular, 
the  respirations  are  deeper,  the  temperature  rises,  the  color  improves,  the  ex- 
pression of  the  patient  becomes  bright,  and  she  loses  the  listless  air  so  character- 
istic of  shock.  But  instead  of  the  reaction  becoming  complete  and  merging  into 
a  normal  convalescence,  traumatic  delirium  may  supervene.  Sometimes  the 
stage  of  depression  may  be  so  short  as  not  to  be  recognized,  and  the  patient  at 
once  becomes  delirious  after  regaining  consciousness,  or  the  delirium  may  be 
preceded  by  prolonged  shock.  The  skin  becomes  flushed,  dry,  and  hot,  the  tem- 
perature rises  above  normal,  the  pulse  is  fuller  and  more  regular,  although  com- 
pressible, the  tongue  is  dry  and  tremulous,  the  thirst  is  urgent,  and,  instead  of 
lying  prone,  the  patient  is  restless  and  tosses  from  one  side  of  the  bed  to  the 
other.  The  delirium  may  be  low  and  muttering  or  of  the  wildest  character.  I 
know  of  instances  in  which  the  patients  have  fallen  out  of  bed,  torn  the  bed- 
clothing  to  pieces,  and  walked  from  one  room  to  the  other,  so  wildly  maniacal 
as  to  require  the  closest  watching  and  restraint. 

This  traumatic  delirium  either  gradually  subsides  and  the  patient  recovers,  or 
it  is  followed  by  extreme  collapse,  the  pallor  again  returns,  the  pulse  becomes 
weak,  thready^  and  is  finally  imperceptible,  and  the  patient  falls  into  a  profound 
stupor  ending  in  death. 


SHOCK,  59 

Late  Shock. — I  have  seen  several  cases  of  profound  shock  coming  on 
several  hours  after  an  operation  for  large  mjomata  ;  although  I  must  admit 
that  these  symptoms  may  have  been  due  to  hemorrhage  which  was  afterward 
absorbed. 

The  case  of  M.  W.,  aged  forty,  No.  3296,  operated  on  Jan.  30,  1895,  was 
a  good  example  of  this  complication.  A  hysteromyomectomy  was  done,  lasting 
forty-three  minutes  in  all,  removing  a  tumor  filling  the  abdomen  and  adherent 
to  the  entire  breadth  of  the  omentum ;  the  patient  took  ether  well,  and  was  put 
to  bed  at  11.30  a.  m.  in  excellent  condition,  with  a  warm  skin  and  a  full,  regu- 
lar pulse,  beating  81  to  the  minute.  The  facial  color  and  expression  were  also 
good. 

At  2.15  p.  M.  a  decided  pallor  of  the  face  was  noted,  the  mucous  membranes 
were  blue,  the  nails  livid,  and  the  pulse  impercej^tible  at  both  wrists.  The  res- 
pirations were  shallow,  she  had  precordial  distress,  and  the  voice  was  weak.  The 
reassuring  features  were  that  the  extremities  were  warm,  and  there  was  no  moist- 
ure on  the  forehead  and  no  nausea.  She  was  stinmlated  with  strychnin,  and 
coffee  and  brandy  by  enemata,  but  the  imj^rovement  was  slow,  and  her  condition 
only  became  normal  after  five  or  six  days. 

Another  case  exhibiting  this  alarming  complication  was  that  of  M.  D.,  3320, 
aged  twenty-nine,  operated  on  Feb.  8,  1895. 

She  was  a  woman  of  ordinary  stature,  with  an  abdomen  enlarged  to  a  cir- 
cumference of  99  centimeters  (40  inches)  by  a  myomatous  uterus,  lifting  the 
bladder  up  to  a  point  just  below  the  umbilicus  and  displacing  the  sigmoid  flex- 
ure above  the  umbilicus.  After  a  difiicult  enucleation  of  this  large  unusually 
vascular  subserous  mass,  lasting  twenty-three  minutes,  she  was  put  to  bed  with 
a  pulse  of  88.  On  the  second  day  the  pulse  began  to  go  steadily  upward,  rang- 
ing between  140  and  150  on  the  third  day,  when  it  was  scarcely  perceptible. 
As  she  showed  no  blanching  and  seemed  bright,  I  simply  stimulated  and 
watched  her.  From  this  time  the  pulse  slowly  came  do\^m,  but  did  not  get 
below  100  again  until  the  twelfth  day.  In  every  other  respect  the  convales- 
cence was  normal. 

Diagnosis. — It  is  important  to  differentiate  the  predisposing  or  exciting 
cause  of  shock,  whether  from  enfeebled  vitality,  prolonged  operation,  hemor- 
rhage, anesthesia,  or  exposure  of  bowel  and  omentum,  as  the  treatment  depends 
largely  upon  the  cause. 

Chl<jroform  asphyxia  must  be  carefully  discriminated  from  shock.  Its  onset 
is  sudden,  with  few  or  no  warning  symptoms,  the  respiration  grows  shallow, 
irregular,  and  finally  ceases,  the  pupils  dilate,  the  face  assumes  an  ashen  hue,  the 
pulse  becomes  M'eak,  entirely  disappearing  at  the  radial  artery.  Upon  the 
prompt  withdrawal  of  the  anesthetic,  the  suspension  of  the  patient  with  head 
downward,  and  the  induction  of  artificial  respiration,  these  symptoms  disai)pcar 
and  the  patient  speedily  returns  to  a  normal  condition.  In  shock,  the  gradual 
appearance  of  the  symptoms,  the  absence  of  precijutate  onset,  and  the  slow  re- 
sponse to  resuscitative  measures  are  marked  differential  ])oints. 

Further,  it  is  of  vital  importance  for  the  surgeon  to  differentiate  promptly 


60  COMPLICATIONS   ARISING    AFTER    ABDOMINAL   OPERATIONS. 

between  the  collapse  associated  with  hemorrhage,  and  shock  from  nervous  de- 
pression. 

Prognosis. — If,  after  a  few  hours,  the  general  condition  of  the  patient 
begins  to  improve,  as  indicated  by  the  return  of  color  to  the  lips,  lessening  pulse 
rhythm,  increase  in  the  surface  temperature,  fuller  or  deeper  respiration,  vomit- 
ing, and  a  desire  to  change  from  the  supine  to  some  other  position,  the  prognosis 
is  favorable.  The  longer  the  reaction  is  delayed,  the  more  serious  becomes  the 
prognosis,  and  if,  after  twenty -four  hours,  there  is  no  change  for  the  better,  each 
hour  thereafter  detracts  from  the  patient's  chance  of  recovery. 

A  temperature  which  persists  at  one  or  two  degrees  below  normal  for  a  num- 
ber of  hours  is  also  a  sign  of  ill  omen,  and  few  cases  recover  in  which  the  tem- 
perature falls  to  96°  or  below.  On  the  other  hand,  when  the  reaction  goes  so 
far  as  to  merge  into  traumatic  delirium,  and  the  temperature  rises  to  103°  or 
above,  the  prognosis  becomes  grave.  A  persistently  rapid  pulse  ranging  be- 
tween 140°  and  160°  is  also  unfavorable,  although  one  or  two  days  may  elapse 
in  some  cases  before  there  is  marked  circulatory  reaction,  and  still  recovery  may 
take  place.  ' 

Preventive  Treatment. — It  is  one  of  the  most  important  duties  of 
the  surgeon  so  to  arrange  and  conduct  his  operations  that  causes  f>i"edisposing 
to  shock  may  be  avoided. 

To  this  end  operations  upon  weak  and  debilitated  patients,  or  upon  those  in 
whom  the  pelvic  disease  is  complicated  by  disease  of  some  other  organ,  must 
be  delayed  until  the  general  condition  can  be  improved  by  tonics,  rest,  and  regu- 
lated diet ;  provided  that  the  advantage  derived  from  this  treatment  is  not  over- 
balanced by  the  progress  of  the  disease  in  the  same  time. 

Operations  should  never  be  performed  in  a  cool  room  ;  the  most  suitable 
temperature  is  from  21°  to  27°  C.  (75°  to  80°  F.). 

Prolonged  exposure  of  the  surface  of  the  body  in  preparing  the  patient  on 
the  operating  table  must  be  avoided,  and  if  during  the  operation  it  is  necessary 
to  lift  the  intestines  out  onto  the  abdomen,  they  should  be  carefully  protected  with 
layers  of  gauze  wrung  out  of  a  hot  salt  solution,  and  a  salt  solution  at  a  tem23er- 
ature  of  43-3°  C,  (110°  F.)  should  be  poured  over  the  gauze  at  frequent  inter- 
vals. The  lower  extremities  and  chest  are  wrajjped  in  warm  blankets,  and  these 
in  turn  are  protected  by  rubber  sheets  to  prevent  them  from  getting  wet ;  a  hot- 
water  can  should  be  placed  between  the  feet,  and  hot-water  bags  down  the  sides 
from  armpits  to  thighs. 

The  anesthetic  must  be  administered  for  as  short  a  time  as  possible,  and  all 
preparations  to  operate  should  be  completed  and  the  surgeon  ready  to  begin  as 
soon  as  the  patient  is  fully  anesthetized. 

Extreme  precaution  must  be  taken  throughout  the  operation  to  avoid  loss  of 
blood  by  the  prompt  clamping  or  ligation  of  actively  bleeding  vessels,  control- 
ling all  possible  sources  of  hemorrhage. 

Immediate  Treatment . — If,  in  spite  of  these  precautions,  shock  takes 
place,  a  reaction  must  be  set  up  as  quickly  as  possible.  This  is  best  accom- 
plished by  the  administration  of  stimulants  and  the  external  application  of  heat. 


SECONDARY    HExMORRHAGE.  61 

As  soon  as  the  symptoms  of  shock  appear,  whether  during  or  after  the  operation, 
a  liypodermic  of  brandy,  3  ss.,  and  sulphate  of  strychnin,  gr,  -Jg-,  should  be 
given,  followed  every  half  hour  or  every  hour  with  a  like  quantity  of  brandy 
and  one  half  the  dose  of  strychnin  (gr.  -^\).  The  intervals  between  the  injec- 
tions must  be  lengthened  if  muscular  twitching  or  a  stiffening  of  the  jaw  is  ob- 
served. Hypodermic  injections,  to  be  quickly  effectual,  should  not  be  given 
into  the  extremities  where  the  circulation  is  ahnost  completely  susj^ended,  but 
into  the  deeper  tissues  of  the  chest,  the  sides  of  the  abdomen,  the  upper  parts 
of  the  thighs,  and  the  deltoid  muscles.  As  a  rapid  cardiac  stimulant,  nitroglyc- 
erin in  the  dose  of  j^^  of  a  grain,  given  hypodermically  every  two  hours,  is  of 
service. 

Stimulating  and  nutritive  enemata  should  also  be  re- 
sorted to  at  once.  The  first  enema  may  be  gi^-en  while  the  patient  is  on 
tlie  table,  and  it  may  be  repeated  at  intervals  of  from  three  to  six  hours.  The 
best  enema  is  made  as  follows  :  Two  ounces  of  brandy,  twenty  grains  of  ammo- 
nium carbonate,  with  sufficient  water  or  beef  tea,  at  a  temperature  of  37"8°  C. 
(100°  F.),  to  make  an  eight-ounce  mixture.  This  should  be  slowly  injected  into 
the  rectum.  Later,  when  reaction  sets  in,  the  brandy  and  carbonate  of  ammo- 
nium may  be  diminished,  and  the  yolks  of  two  or  more  eggs  added. 

The  patient's  bed  should  be  thoroughly  heated  with  hot-water  bags  or  cans 
enveloped  in  flannel,  i3laced  between  the  blankets  half  an  hour  before  the  com- 
pletion of  the  operation.  After  the  j)atient  is  transferred  to  bed  great  care 
should  be  observed  to  keep  the  bags  or  cans  at  a  safe  distance  from  her  body. 
Extensive  burns  of  the  second  and  third  degree  have  resulted  from  the  careless- 
ness of  the  nurse  in  not  watching  the  hot-water  bags  closely  enough.  The 
j^atient  is  placed  between  blankets  mth  her  head  low,  to  jDrevent  nausea  and 
syncope,  and  if  the  shock  has  been  associated  with  much  loss  of  blood,  the  foot 
of  the  bed  should  be  elevated  six,  eight,  or  twelve  inches. 

In  patients  suffering  from  shock  the  stomach  may  tolerate  a  large  amount  of 
fluid  administered  by  the  anxious  attendant,  but  this  should  not  deceive  the  sur- 
geon, for  there  is  little  or  no  absorption  from  the  stomach.  To  derive  the  full 
benefit  of  nourishn;ent  and  stimulants,  they  should  be  given  in  very  small  quan- 
tities— not  more  than  two  or  three  ounces  in  an  hour.  Gentle  friction  with  alco- 
hol may  be  employed  later,  when  reaction  has  set  in. 

When  shock  has  resulted  from  exhausting  hemorrhage,  the  salt  solution 
infusion  must  be  resorted  to  when  the  radial  pulse  is  much  quickened. 

Secondary  Hemorrhage. — One  of  the  most  frightful  accidents  which  can  occur 
after  an  abdominal  o])eration  is  secondary  hemorrhage.  The  i)elvic  organs  are 
so  richly  supplied  with  blood  through  large  vascular  channels  that  death  may 
occur  in  a  sh<n-t  time  if  one  of  the  ligatures  controlling  an  important  artery  or 
vein  slips  off  after  the  completion  of  any  major  gynecological  operation.  The 
occurrence  of  such  a  hemorrhage  is  always  due  to  some  error  in  the  technique 
of  the  operation,  and  is  therefore  especially  liable  to  happen  in  the  hands  of  an 
inexperienced  surgeon.  In  my  earliest  work  I  met  with  it  as  often  as  once  in 
about  every  hundred  abominal  cases,  but  by  adopting  certain  stringent  precautions 


62  COMPLICATIONS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 

I  have  been  able  to  eliminate  it  almost  to  a  certainty  as  a  complication.     In  1,800 
abdominal  sections  at  the  Johns  Hopkins  Hospital  there  have  been  8  cases  of 
extensive  hemorrhage  into  the  peritoneum  following  operation.     One  of  these 
died  and  7  recovered  after  opening  the  abdomen  and  checking  the  flow. 
Causes . — The  chief  causes  of  secondary  hemorrhage  are : 

1.  Defective  tying. 

2.  Cutting  too  close  to  a  ligature. 

3.  Undue  traction  on  the  ligature  after  tying. 

4.  The  shrinkage  of  the  tissues  within  the  grasp  of  the  ligature. 

5.  An  extensive  capillary  oozing. 

How  to  avoid  Plemorrhage  by  Care  during  Operation. 
— The  most  dangerous  method  of  securing  a  pedicle  is  the  simple  transfixion 
with  an  aneurysmal  needle  carrying  two  ligatures  and  tying  the  pedicle  both 
ways.  This  is  peculiarly  dangerous  when  the  ligature  is  applied  to  structures 
springing  from  the  top  of  the  broad  ligament.  A  ligature  applied  at  this  point 
is  practically  placed  upon  the  apex  of  a  pyramid,  and  the  marvel  is  that  it  does 
not  more  frequently  slip  over  the  summit,  setting  free  the  blood  vessels.  The 
risk  of  such  an  accident  is  increased  by  yielding  to  the  common  inclination  to 
amputate  the  ovary  and  the  tube  as  close  as  possible  to  the  ligatures.  It  is  evi- 
dent also  that  a  slight  pressure  upon  the  uterus  will  now  drag  the  broad  Hga- 
ment  out  of  the  grasp  of  one  or  both  ligatures.  A  careless  plunging  of  the 
sponge  held  in  a  holder  down  into  the  pelvis,  without  taking  precautions  to 
avoid  striking  the  to]3  of  the  uterus  or  the  broad  ligaments,  becomes  especially 
dangerous  in  this  connection. 

After  the  abdomen  is  closed  the  straining  efforts  of  vomiting  or  coughing  by 
foi'cing  the  viscera  down  on  the  uterus  and  broad  ligaments  may  produce  the 
same  effect. 

Catgut  tied  in  an  ordinary  square  knot  and  cut  close  will  often  swell  and 
soften,  and  so  become  untied  and  give  rise  to  hemorrhage. 

When  tissues  are  edematous  or  excessively  vascular,  the  attempt  to  include 
a  large  area  in  a  single  ligature  is  dangerous,  because  they  may  shrink  soon  after 
the  operation  and  so  loosen  the  ligature. 

Extensive  adhesions  to  the  anterior  abdominal  wall  and  to  the  pelvic  walls 
are  sometimes  the  source  of  a  prolonged  capillary  oozing ;  or  bleeding  omental 
vessels,  torn  in  breaking  up  adhesions,  may  be  overlooked  and  give  rise  to  profuse 
hemorrhage  in  the  upper  part  of  the  abdomen. 

The  following  precautions  should  be  taken  during  every  operation  to  avoid 
the  risk  of  hemorrhage  : 

None  but  the  long,  thin  pedicles  of  ovarian  tumors  should  ever  be  treated  by 
transfixing  and  ligating  both  ways,  and  then  the  pedicle  should  be  severed  at 
least  a  centimeter  and  a  half  beyond  the  ligature. 

Wherever  large  blood  vessels  are  tied  it  is  safest  to  use  silk ;  catgut  alone 
should  not  be  relied  upon.  All  large  vessels,  such  as  the  uterine  and  the  ova- 
rian, should  be  tied  twice,  first  with  silk,  then  the  mouths  of  the  vessels  should 
be  caught  and  tied  with  catgut. 


SECONDARY    HEMORRHAGE.  63 

In  the  removal  of  ovaries  and  tubes  for  pyosalpinx  and  hydrosalpinx,  small 
tumors  and  myomata,  two  or  three  ligatures  should  he  carried  through  the  broad 
ligament  with  needle  and  carrier,  the  outermost  ones  grasping  but  a  small 
amount  of  tissue  and  including  the  important  vessels  in  the  manner  described  in 
Chapter  XX. 

In  sponging  posterior  to  the  uterus  and  broad  ligament,  the  uterus  should  be 
held  forward  ^vith  index  and  middle  fingers  of  the  left  hand  resting  on  sacrum 
and  fundus,  furnishing  a  safe  guide  for  the  sponge  in  its  holder.  Continued 
capillary  oozing  from  any  quarter  must  be  noted  and  stopped  by  suture,  pucker- 
ing the  tissues  together,  or  by  coating  the  tip  of  the  finger  with  a  thin  layer  of 
powdered  persulphate  of  iron  and  then  making  firm  pressure  on  the  spot  for 
about  half  a  minute  ;  the  finger  is  then  gently  and  slowly  removed,  and  in  most 
cases  the  bleeding  stops  with  a  single  application.  The  oozing  may  also 
sometimes  be  checked  by  making  pressure  upon  the  part  with  a  sponge  wrung 
out  of  water  so  hot  that  the  hands  can  not  be  put  into  it.  The  sponge  is  wrung 
out  between  layers  of  gauze  and  applied  for  half  a  minute. 

In  the  extensive  raw  areas  left  after  stripping  off  intestinal  or  omental  adhe- 
sions, or  after  the  enucleation  of  dense  inflammatory  masses  or  an  adherent 
tumor,  there  may  be  a  great  many  oozing  points,  the  bleeding  from  any  one  of 
which  would  be  infinitesimal,  but  all  taken  together  may  cause  a  dangerous  loss 
of  blood.  Some  of  these  oozing  areas  require  skill  and  patience  in  order  to 
check  the  flow.  Where  the  oozing  areas  are  situated  on  the  peritoneal  and 
muscular  coats  of  the  intestine,  or  on  the  posterior  surface  of  the  uterus,  the 
best  means  of  controlling  it  is  to  pass  numerous  fine  catgut  sutures  very  super- 
ficially. A  quadrangular  or  circular  suture  will  usually  serve  a  better  purpose  in 
these  cases  than  the  simple  interrupted  stitch  ;  care,  however,  must  be  observed 
in  introducing  them  not  to  perforate  the  bowel  nor  to  include  enough  tissue  to 
cause  a  narrowing  of  the  Ijowel  when  the  suture  is  tied. 

When  the  oozing  is  free  and  can  not  be  checked  and  the  patient  begins  to 
show  decided  signs  of  exhaustion,  I  desist  from  further  attempts  and  resort  to 
a  gauze  drain. 

If  the  pulse  is  good  and  the  general  condition  fair,  I  would  prefer  to  close 
the  abdomen  and  leave  a  limited  amount  of  oozing,  rather  than  to  employ  any 
form  of  drainage,  on  account  of  the  risks  of  infection. 

In  cases  where  the  operation  has  been  extensive  and  where,  as  the  result  of 
the  enucleation,  there  are  extensive  raw  areas  and  the  patient  is  in  a  critical  con- 
dition, it  may  be  necessary  to  put  a  firm  gauze  pack  into  the  i)elvis  by  inserting 
a  long  strip  packed  firmly  against  the  raw  surfaces  and  brought  out  at  the  lower 
angle  of  the  incision. 

The  difiiculty  in  removing  the  drain  in  these  cases  is  even  greater  than  in 
suppurative  cases,  because  the  plastic  lymph  thrown  out  between  the  gauze  and 
the  raw  surfaces  is  very  tenacious  and  the  early  removal  is  attended  with  intense 
pain,  and  the  risk  of  pulling  out  omentum  and  intestines,  or  even  of  dislodging 
an  important  ligature,  and  so  setting  up  anew  a  free  oozing.  This  accident  has 
occurred  once  in  the  gynecological  wards  of  the  Johns  Hopkins  Hospital.     A 


Q4:  COMPLICATIOXS    ARISIXG    AFTER    ABDOMINAL    OPERATIONS. 

large  drain  had  been  put  in  to  check  the  free  oozing  following  the  enucleation 
of  dense  inflammatory  masses  from  the  pelvis.  The  operation  was  done  on  a 
Saturday  morning,  and  Sunday  morning,  twenty-four  hours  later,  the  patient 
was  doine:  so  well  that  it  was  thought  best  to  remove  the  drain.  Considerable 
force  was  required  to  start  it,  and  then  it  came  away  easily.  At  this  time  the 
patient's  pulse  was  good  and  her  general  condition  excellent.  An  hour  later 
the  pulse  had  increased  in  rate  and  was  not  so  full  in  volume.  From  this  time 
on  her  condition  grew  steadily  worse,  until  the  symptoms  of  an  internal  hemor- 
rhage were  decided,  when  the  abdomen  was  reopened  and  a  large  amount  of 
free  blood  found.  ISTotwithstanding  the  most  careful  search,  however,  it  was 
impossible  to  detect  the  bleeding  points,  and  a  second  drain  was  inserted  ;  under 
the  administration  of  a  saline  infusion  and  cardiac  stimulants,  the  pulse  im- 
proved and  the  danger  seemed  to  be  passed,  when,  without  warning,  respirations 
ceased,  and,  in  spite  of  vigorous  and  prolonged  attempts  at  artificial  respiration, 
the  patient  died  in  a  short  time. 

Bleeding  omental  vessels  may  be  discovered  by  laying  the  omentum  on  a 
clean  piece  of  gauze,  when  the  spots  of  blood  will  indicate  the  position  of  any 
oozing  areas. 

Hemorrhage  from  the  walls  of  the  abdomen  may  l)e  detected  in  the  same 
way  by  laying  a  piece  of  gauze  on  the  intestines  under  the  spot. 

One  of  the  most  important  ways  of  avoiding  hemorrhage  is  the  making  of  a 
final  thorough  inspection  of  every  part  of  the  field  of 
operation  just  before  closing  the  abdomen,  when  any  bad  ties  are  found  out 
and  reinforced,  and  concealed  bleeding  areas  may  be  discovered. 

Symptoms . — A  secondary  hemorrhage  may  occur  at  any  time  within 
forty-eight  hours  after  the  operation  is  over.  It  may  even  begin  while  the 
patient  is  still  in  the  operating  room,  and  go  on  until  the  symptoms  produced 
are  pronounced  enough  to  draw  attention  to  the  patient's  condition.  These 
symptoms  will  appear  with  a  rapidity  directly  in  proportion  to  the  previous  good 
or  ill  condition  of  the  woman  and  to  tlie  activity  of  the  hemorrhage. 

Bleeding  from  capillary  vessels  in  areas  bared  by  peeling  off  adhesions  rarely 
exceeds  60  or  90  centimeters  (2  or  3  ounces),  and  does  not  produce  serious 
symptoms  attrilmtable  to  the  loss  of  blood.  The  greatest  danger  from  this 
source  is  the  liability  to  subsequent  infection  of  the  unabsorbed  mass  of  blood. 

Hemorrhage  from  uterine  or  ovarian  vessels,  or  from  branches  of  the  uterine 
artery  in  the  substance  of  the  uterus,  or  from  a  large  omental  vessel,  is  so  rapid 
that  within  a  short  time — fifteen  minutes  or  half  an  hour — it  gives  rise  to  a  defi- 
nite train  of  symptoms.  The  actual  amount  of  blood  poured  out  in  a  given 
time  from  a  uterine  or  an  ovarian  artery  will  depend  upon  its  size,  varying 
markedly  in  different  individuals  ;  the  quantity  is  largest  in  the  case  of  uterine 
fibroids,  where  a  bleeding  uterine  or  ovarian  vessel  may  very  quickly  termi- 
nate a  patient's  life  before  any  measure  can  be  employed  to  save  her. 

An  illustration  of  this  statement  occurred  in  my  wards  at  the  Johns  Hop- 
kins Hospital.  A  patient  had  been  operated  upon  for  a  large  symmetrical 
myoma  ;  the  vessels  were  all  securely  tied,  and  she  made  an  uninterrupted  con- 


SECONDARY   HEMORRHAGE.  65 

valesence  until  the  eiglith  day.  At  noon  of  that  day  she  suddenly  cried  out,  and 
when  the  nurse  hurried  to  her  she  complained  of  great  pain  in  the  left  inguinal 
reo-ion.  Her  pulse  was  very  rapid,  and  her  expression  anxious.  A  resident  at 
once  hurried  to  the  ward,  arriving  there  in  fifteen  minutes  ;  but  by  this  time  the 
pulse  had  become  imperceptible,  and  the  patient  was  in  a  dying  condition.  The 
collapse  was  so  sudden  that  the  diagnosis  of  puhnonary  embolus  was  made. 
The  autopsy  showed  that  there  was  a  tremendous  hemorrhage  from  the  uterine 
artery  from  the  absorption  and  rupture  of  the  catgut  ligature,  which  allowed  the 
organizing  thrombus  to  be  pushed  out  of  the  short  stump  of  the  artery. 

If  the  l)leeding  takes  place  in  an  abdomen  with  a  gauze  drain  in  it,  there 
will  be  no  difficulty  in  knowing  precisely  what  has  occurred.  Something  about 
the  patient's  condition  or  expression  or  color  excites  attention,  and  when  the 
bedclothes  are  thrown  down  the  bandage  is  found  wet  through  with  blood.  The 
dresshigs  are  saturated,  and  on  pulling  the  drain  out  a  little  the  flow  continues 
actively. 

The  usual  train  of  symptoms  in  hemorrhage  are  : 

1.  Sudden  quickening  of  the  pulse  and  diminution  in  volume  without  appa- 
rent cause,  or  even  an  entire  loss  of  the  pulse. 

2.  Quickened  sighing  respiration,  and  the  use  of  the  extraordinary  muscles 
of  respiration. 

3.  Increasing  pallor  and  a  pearly  conjunctiva. 

4.  Cold,  clammy  skin. 

5.  Yertigo. 

6.  Kestlessness,  throwing  the  arms  and  legs  from  side  to  side. 

7.  Desire  to  be  raised  in  bed  (orthopnea). 

8.  Pain  in  the  abdomen,  often  severe. 

9.  Vomiting  sometimes. 

The  history  is  often  as  follows  :  The  patient  begins  by  complaining  of  pain 
in  the  lower  abdomen  ;  her  color  seems  a  little  paler,  and  the  pulse  somewhat 
quickened.  The  pain  comes  on  in  paroxysms  and  is  diffused.  She  wears  an 
anxious  expression,  and  she  may  insist  on  seeing  the  doctor  at  once,  fearful 
that  she  is  not  doing  well.  The  radial  pulse  quickly  becomes  diminished  in  vol- 
ume, while  its  rhythm  is  increased  from  twenty  to  thirty  or  more  beats  ;  the  legs 
and  arms  become  cold  as  the  hemorrhage  continues,  and  the  radial  pulse  finally 
fails  altogether,  or  becomes  so  faint  that  it  can  be  detected  with  difficulty.  The 
physician  arrived  at  the  bedside,  feels  no  pulse  at  all,  unless  it  is  the  pulsation  in 
his  own  finger  tips  as  they  are  pressed  deep  into  the  wrist  in  his  anxiety  to  dis- 
cover some  faint  beats.  The  face  assumes  an  ashen  hue,  the  conjunctivarmu- 
cosa  is  no  longer  injected,  the  lips  are  blue  and  the  gums  blanched.  A  cold 
perspiration  breaks  out  on  the  face,  and  the  respiration  is  quickened  and  labored. 
The  temperature  is  subnormal.  She  lies  flat  on  her  back  with  chin  elevated  to 
make  the  breathing  less  difficult,  and,  although  restless  and  anxious,  remains  mo- 
tionless, except  for  an  occasional  tossing  of  the  head  from  side  to  side  as  the 
dyspnea  increases.     She  knows  that  her  condition  is  changed,  but  often  does 

not  appreciate  the  gravity  of  the  situation. 
45 


66  COMPLICATIONS    ARISING    AFTER    ABDOMINAL    OPERATIONS. 

If  the  bleeding  continues  unchecked,  death  ensues  in  a  period  varying  from 
six  to  twenty-four  hours,  or  even  longer,  depending  upon  the  size  of  the  vessel 
and  the  anemic  or  plethoric  condition  at  the  outset.  After  attacks  of  bilious 
vomiting  the  dyspnea  often  increases. 

The  accessory  respiratory  muscles  of  the  neck  come  into  play  toward  the 
last,  and  she  complains  of  a  painful  or  heavy  sensation  in  the  cardiac  region. 
This  is  apt  to  signalize  the  beginning  of  heart  failure.  With  the  increasing 
dyspnea  comes  a  sense  of  suffocation  and  desire  to  have  the  head  raised  with 
pillows  placed  beneath  the  shoulders.  The  distress  and  the  half  ai-ticulated 
gasping  requests  of  the  patient  at  this  time  are  peculiarly  distressing  to  the  by- 
standers. The  heart  impulse  may  still  be  distinctly  felt,  regular,  but  sudden, 
short,  and  violent,  on  placing  the  hand  gently  over  the  precordium.  Gradually, 
as  life  ebbs  away,  the  pupils  dilate  and  a  condition  of  apparent  obliviousness 
supervenes,  although  even  this  state  may  be  occasionally  interi-upted  by  a  hur- 
ried gasping  ejaculation,  showing  that  some  consciousness  still  remains.  Com- 
plete unconsciousness  gradually  conies  on,  the  breathing  becomes  short  and 
gasping,  the  corners  of  the  mouth  are  drawn  out  and  expanded  in  a  hideous 
risus,  when  at  last,  after  one  or  two  shallow  gasping  efforts,  respiration  ceases 
altogether.  The  heart  continues  to  beat  some  time  after  respiration  has  ceased, 
and  after  the  pulsations  are  no  longer  felt  a  sHght  ticking  or  faint  contraction, 
more  or  less  rhythmical,  may  be  detected  for  half  a  minute  or  more,  and  the 
tragic  scene  is  at  an  end. 

This  accident  may  happen  in  the  best  hands,  but  in  the  great  majority  of 
cases  the  patient  can  be  saved  by  promj)t  action.  Eight  post-operative  hemor- 
rhages have  occurred  in  a  series  of  1,800  abdominal  sections  in  my  service  at  the 
Johns  Hojjkins  Hospital  with  only  one  death.  The  two  following  cases  are 
cited  as  typical  illustrations  of  the  usual  course  and  symptoms  of  this  accident : 

M.  E,.,  2752,  Sept.  8,  1894: ;  operation  simple  salpingo-oophrectomy.  Care- 
ful ligation  of  uterine  and  ovarian  vessels  separately ;  suspension  of  the  uterus. 
The  risks  of  hemorrhage  dwelt  upon  at  the  operation,  and  ties  carefully  made 
to  prevent  it.  Returned  at  12  o'clock  to  her  room  in  excellent  condition. 
Vomited  violently  at  3  p.  m.,  when  her  jDulse  was  Gi) ;  at  3.40  p.  m.,  the  pulse 
128,  weak,  compressible,  pallor  marked,  the  lips  dry  and  marbled,  and  thirst 
intense  ;  dyspnea ;  extremities  cold. 

Abdomen  reopened  at  7  p.  m.  Blood  spouted  up  toward  the  ceiling  on  open- 
ing the  peritoneum,  which  was  full  of  fluid  blood  ;  large  clots  ladled  out  of  both 
flanks.  At  this  time  the  patient  was  pulseless  at  the  wrist ;  160  beats  per  minute 
felt  at  the  heart.  The  ligature  at  the  left  cornu  uteri  was  found  loose  ;  this  was 
reapplied  lower  do^vn  in  the  course  of  the  artery  ;  after  all  the  clots  were  taken 
out  the  abdomen  was  irrigated  with  a  salt  solution,  and  an  infusion  was  given 
into  the  radial  artery  to  the  amount  of  750  centimeters  of  normal  salt  solution  ; 
following  this  the  pulse  reappeared  at  wrist  in  two  minutes,  and  the  patient 
recovered  and  is  in  good  health. 

C.  L.,  1920,  April  19,  1893,  salpingo-oophorectomy,  removing  hematoma  of 
left  ovary.     Pulse  92-112,  fair  volume. 


SECOXDARY    HEMORRHAGE.  67 

Six  Lours  later  Yomiting ;  pulse  suddenly  became  irregular  and  almost  im- 
perceptible, rate  160.  Dyspnea  marked ;  pain  in  epigastrium,  sides  of  chest,  and 
flanks.  Intense  thirst,  frequent  vomiting  of  dark-green  fluid,  extreme  pallor  and 
restlessness. 

Operation  in  patient's  room  in  bed ;  abdomen  reopened  under  cocain,  found 
filled  with  blood.  Ligature  at  the  cornu  uteri  found  loose.  Blood  removed  and 
abdomen  flushed  out  with  salt  solution. 

Infused  into  radial  artery  700  centimeters  of  normal  salt  solution.    Recovery. 

Shock  is  one  of  the  most  important  conditions  liable  to  be  confused  with  sec- 
ondary hemorrhage  in  making  a  differential  diagnosis.  Shock,  however,  does 
not  come  on  suddenly  some  hours  after  operation,  and  is  gradual  in  its  onset. 
If  the  patient  has  been  carefully  watched,  it  will  often  be  evident  that  her 
shocked  condition  is  but  the  continuance  of  a  state  existing  immediately  after 
operation.  Such  shock,  it  is  true,  is  often  associated  with  an  excessive  loss  of 
blood  during  the  operation.  It  is  more  profound  when  in  addition  to  loss 
of  blood  is  added  the  depression  of  a  protracted  operation  in  a  feel)le  subject. 

The  differential  diagnosis  between  hemorrhage  and  a  septic  infection  may 
sometimes  be  impossible  if,  instead  of  a  gradual  onset,  the  septic  symptoms 
appear  suddenly.  In  either  case  the  treatment  by  abdominal  section  is  the 
same.     I  quote  one  case  as  an  illustration  of  the  possibility  of  this  confusion : 

L.  F.,  2612,  March  1,  ISO-t,  operation  for  right  extra-uterine  pregnancv, 
walled  off  by  adhesions  and  choking  the  pelvis  posterior  to  the  uterus  in  an 
excessively  fat  woman  ;  a  vaginal  incision  was  made  posterior  to  the  cervix, 
emptying  the  sac,  followed  by  irrigation  and  packing  with  gauze. 

After  removal  of  the  pack  on  the  third  day  the  irrigations  were  continued 
every  second  day  with  a  5  per  cent  boric  solution,  followed  by  the  introduction 
of  a  fresh  gauze  pack. 

Nine  days  after  the  operation  the  patient  was  out  of  bed  "  doing  excellently." 
Some  pain  and  pallor  were  evident  on  the  tenth  and  twelfth  days.  On  the 
twelfth  day  the  irrigation  fluid  did  not  return  freely,  and  there  was  a  discharge 
of  some  matter  and  shreds  of  tissue ;  she  screamed  with  pain,  and  the  pulse  be- 
came suddenly  weak  and  almost  imperceptible.  She  Avas  bathed  in  a  cold  sweat, 
and  hands  and  nails  were  white  and  the  respirations  rapid.  There  was  pain  in 
the  hypogastrium,  followed  by  cyanosis,  the  pulse  kept  growing  more  rapid  and 
weaker,  with  slight  abdominal  distention,  and  no  tenderness  or  tenseness.  Within 
five  hours  all  the  synqjtonis  of  collapse  were  pronounced. 

A  diagnosis  of  secondary  hemorrhage  was  made ;  the  patient,  with  a  jiulse 
of  170,  was  taken  at  once  to  the  operating  room  and  put  under  chloroform  anes- 
thesia. As  soon  as  the  abdomen  was  opened,  about  a  liter  of  thin  milky  tluid, 
with  shreds  of  tissue  floating  in  it,  escaped.  The  peritoneum  was  rod  and  in- 
jected everywhere,  and  necrotic  areas  Avere  found  on  top  of  the  sac  in  the  pelvis, 
with  a  perforation  comnuinicating  with  the  sac  and  so  with  the  vagina.  The 
abdomen  was  thoroughly  washed  out  with  salt  solution,  and  gauze  drainage  pro- 
vided at  three  openings,  one  at  the  lower  angle  of  the  incision,  and  one  well  back 
in  each  flank,  communicating  with  the  central  one.     The  drains  were  removed 


68  COMPLICATIOXS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 

on  tlie  third  day  co veered  with  a  purulent  discharge  ;  following  this  there  was  a 
rapid  improvement  and  recovery. 

It  is  of  the  utmost  importance  for  the  operator,  his  assistants,  and  the  nurses 
in  every  case  to  note  the  general  appearance  and  the  color  of  the  mucous  mem- 
branes of  the  patient  as  she  leaves  the  operating  room,  in  order  that  they  may 
have  a  satisfactory  standard  for  comparison  in  case  the  question  of  hemorrhage 
comes  up  at  a  later  date. 

Operation . — Having  once  arrived  at  a  diagnosis  of  secondar}'  hemorrhage, 
no  time  must  be  lost  in  carrying  out  the  boldest  measures  to  check  the  flow, 
and  in  making  up  for  the  deficient  volume  of  blood  by  infusion. 

To  check  the  hemorrhage,  all  necessary  instruments  and  accessories  should 
always  be  within  easy  access  wherever  there  is  a  patient  upon  whom  an  abdomi- 
nal operation  has  been  performed. 

In  the  hospital  it  is  always  best  to  take  the  patient  back  to  the  conveniences 
of  the  operating  room  if  it  is  safe  to  move  her  at  all.  The  preparations  are  there 
made  for  opening  and  washing  out  the  abdomen  and  catching  and  tying  the 
bleeding  vessel,  and  possibly  closing  the  wound  with  drainage. 

If  the  operation  is  at  a  private  house  or  the  patient  is  too  weak  to  be  taken 
out  of  her  room,  a  table  j^added  with  a  Ijlanket  and  covered  with  a  sheet  should 
be  placed  near  a  window  or  under  the  gas  jet,  and  upon  this  the  inflated  ovari- 
otomy cushion  is  laid.  The  patient  is  then  lifted  upon  the  table.  The  nurse 
in  the  meantime  has  given  her  a  hypodermic  injection  of  one  sixtieth  of  a  grain 
of  strychnin  and  a  half  ounce  of  brandy.  These  injections  should  be  repeated 
every  half  hour  until  she  has  well  rallied.  Two  clean  basins  are  placed  on  chairs 
by  the  table,  and  the  irrigator  bag  is  filled  with  water,  at  a  temperature  of  about 
43-3°  to  46°  C.  (110°  to  115°  F.),  and  suspended  near  the  table.  The  instru- 
ments are  laid  on  a  sterilized  towel  within  convenient  reach. 

While  the  operation  is  in  progress  the  servant  should  prepare  hot-water 
bottles,  wrap  them  in  flannel,  and  lay  them  in  the  bed,  so  that  it  will  be  warm 
when  the  jjatient  is  put  back  in  it. 

Preparations  are  also  made  to  give  the  patient  an  enema  of  brandy  (2  ounces  = 
60  cubic  centimeters)  in  beef  tea  (8  ounces  =  240  cubic  centimeters),  with  annno- 
nium  carbonate  (20  grains  =  1*25  gramme),  as  soon  as  the  operation  is  over. 

The  bladder  is  catheterized.  No  time  is  lost  in  making  elaborate  jjrepara- 
tions ;  rather  the  operator  must  incur  some  risk  of  contamination  for  the  sake 
of  speed.  If  a  good  table  is  not  convenient,  or  the  patient  is  in  an  alarming 
condition,  the  operation  may  be  done  on  her  bed.  A  nominal  amount  of  anes- 
thetic is  used,  and  pushed  to  unconsciousness  at  the  moment  the  incision  is  re- 
opened. The  operator  devotes  two  or  three  minutes  to  scrubbing  his  hands  and 
arms.  The  dressing  covering  the  wound  is  rapidly  laid  aside  and  the  sutures 
exposed.  Beginning  at  the  lower  angle,  two  or  three  sutures  are  cut  and  re- 
moved, the  lips  of  the  incision  sej^arated,  and  the  peritoneum  pulled  up  and  cut 
open  with  the  scissors.  If  the  diagnosis  is  correct,  dark  blood  at  once  wells  up 
and  flows  out  over  the  surface  of  the  abdomen.  No  time  must  be  wasted  in 
trying  to  sponge  all  the  blood  out,  but  the  wound  must  be  enlarged  and  two 


SECOXDARY    HEMORRHAGE.  69 

fingers  carried  down  into  the  pelvis,  to  the  uterus,  and  laterally  out  to  the 
ovarian  stumps.  The  side  where  the  ligature  has  slipped  will  feel  lax  in  con- 
trast to  the  tiglit  bunching  of  the  ligated  pedicle  on  the  other  side.  If  no 
marked  difference  is  recognized,  both  pedicles  must  be  brought  up  and  tied 
over  again,  taking  either  indifferently  first. 

The  broad  ligament  is  best  exposed  by  carrying  a  pair  of  bullet  forceps  down 
into  the  pehds,  into  the  pool  of  blood,  guided  to  the  cornu  simply  by  the  index 
finger.  The  forceps  are  then  opened  and  the  cornu  grasped  and  dragged  up 
into  the  wound  and  exposed,  and  the  vessels  clamped  with  a  stout  pair  of  artery 
forceps. 

The  outer  extremity  of  the  broad  ligament  is  next  exposed,  using  the  sponge 
rapidly  to  clear  away  the  blood.  This  is  clamped,  too,  unless  the  ligature  is  evi- 
dently so  tight  in  place  that  there  can  be  no  question  as  to  the  ^possibility  of 
hemorrhage  from  that  point.  The  opposite  side  is  dealt  with  in  like  manner. 
Any  other  areas  wounded  in  the  operation  are  now  carefully  inspected. 

If  the  operation  has  been  a  hysterectomy,  the  uterine  stum^)  must  be  grasped 
at  once  A\'ith  bullet  forceps  and  pulled  well  up  into  view.  If  the  inspection  of 
the  field  reveals  the  23oint  of  hemorrhage  the  operator  passes  a  fresh  ligature, 
so  as  to  control  the  trunk  below  the  wound,  and  another  to  its  free  end.  If 
the  source  does  not  appear  at  once  he  loses  no  time,  but  proceeds  to  ligate 
both  ovarian  and  both  uterine  arteries  and  veins  at  a  point  beyond  the  field  of 
operation.  The  lower  abdomen  and  pelvis  are  cleansed  by  thorough  repeated 
irrigations  with  a  warm  salt  solution,  diluting  and  washing  out  the  blood,  and 
bringing  out  clots  lodged  among  the  intestines. 

Finally  all  layers  of  the  abdominal  wall  are  united  by  silkworm-gut  sutures, 
closing  the  incision  from  end  to  end.  The  wound  is  redressed  and  the  fresh 
bandage  applied. 

In  case  of  excessive  loss  of  blood,  the  legs  and  arms  should  be  wrap])ed 
tightly  with  flannel  bandages  from  the  extremities  up  to  the  body,  to  keep  the 
blood  in  the  head  and  trunk ;  this  is  further  aided  by  keeping  the  foot  of  the 
bed  elevated  on  a  chair  20  to  3(>  centimeters  (S  or  lo  inches)  high. 

The  hot  rectal  enema  of  60  to  90  cubic  centimeters  (2  to  3  ounces)  of  brandy 
and  30  grammes  of  ammonium  carbonate  in  a  liter  of  normal  salt  solution  is  now 
given  on  the  operating  tal)le.  Hot  bottles  are  put  about  the  chest  and  abdomen 
in  the  l)ed.  It  must  be  rememl)ered  that  during  shock  little  or  nothing  is 
absorbed  from  the  stomach;  and  so  long  as  the  cold,  clammy,  shocked  condition 
persists,  no  amount  of  fluid  ingested  will  satisfy  the  thirst.  As  soon  as  there  is 
some  reaction  the  l)est  way  to  satisfy  the  thirst  is  to  give  an  enema  of  a  pint  of 
warm  beef  tea,  and  to  repeat  it  in  two  or  three  hours. 

The  hypodermics  of  strychnin  should  be  given  in  or  near  the  trunk,  a  six- 
tieth of  a  grain  every  hour,  or  even  every  half  hour;  if  muscular  twitching  is 
noticed,  the  dose  should  be  diminished.  With  this  treatment  the  pulse  drops 
from  IGO  to  140,  and  so  on,  1(»  or  2(»  beats  each  twenty-four  hours,  until  it  is 
again  normal. 

ThejJrofound  anemia  may  last  for  weeks  or  months,  and  is  not  to  be  relieved 


70 


COMPLICATIONS   ARISING    AFTER   ABDOMINAL   OPERATIONS. 


by  a  routine  use  of  iron ;  but  the  better  course  is  by  hygienic  measures  com- 
bined by  tonics,  the  hypophosphites  and  gentian,  with  arsenic  and  strychnin. 

Infusion . — Infusion  of  salt  solution  furnishes  the  quickest  and  best  means 
of  stimulation  we  possess,  and  is  called  for  in  all  cases  of  hemorrhage. 

For  a  long  time  I  employed  infusion  of  normal  salt  solution  into  the  radial 
veins,  but  gave  it  up  in  favor  of  the  arterial  infusion,  because  in  the  latter  the 


Fig.  326. — Introducing  Normal  Salt  Solution  under  the  Breasts  in  Case  or  Extreme  Anemia. 

The  form  of  the  breast  before  the  injection  is  seen  on  the  right  side,  where  the  trocar  has  just  been  intro- 
duced beneath  the  gland;  on  the  left  side  the  breast  is  fully  distended  by  half  a  liter  of  the  solution. 


fluid  enters  the  artery  and  is  forced  up  the  vessel  until  the  first  branches  are 
reached,  whence  it  flows  back  through  the  capillaries  and  is  filtered,  by  which  it 
is  diffused  with  the  blood  in  a  more  even  mixture  than  when  the  entire  volume 
of  the  infusion  is  injected  into  the  veins.  Infusion  against  the  blood  current 
has  also  a  distinct  stimulating  effect  upon  the  heart. 


PECULIARITIES    OF   THE    PULSE.  71 

After  repeated  ill  exi^eriences  with  the  arterial  infusion  I  was  finally  com- 
pelled to  give  it  up.  The  force  necessary  to  inject  the  salt  solution  against  the 
stream  of  arterial  blood  causes  a  much  greater  distention  of  the  coats  of  the  ves- 
sel than  is  normal,  and  it  is  probable  that  the  vessel  is  permanently  injured ;  in 
my  experience  serious  sloughing  around  the  area  of  infusion  has  occurred  in 
four  cases ;  in  one  instance  the  entire  hand  had  to  be  amputated  some  months 
later. 

The  infusion  of  saline  solution  into  the  cellular  tissues  under  the  breasts  is 
so  free  from  any  sequelae  and  is  so  easily  given,  and  affords  such  prompt  relief, 
that  I  now  use  it  in  all  cases  of  hemorrhage,  and  even  where  the  patient  is  but 
slightly  depressed  by  the  loss  of  blood. 

The  method  of  giving  the  infusion  is  simple.  I  have  had  graduated  bottles 
made  especially  for  this  purpose,  which  are  filled  with  1,000  cubic  centimeters 
of  the  salt  solution  (0-6  per  cent)  at  a  temperature  of  100°  F.  (37-8°  C).  A 
rubber  tube  six  feet  long,  to  which  is  attached  a  long,  slender,  sharp  aspirating 
needle,  completes  the  apparatus. 

The  solution  must  be  free  from  all  organic  particles,  such  as  bits  of  cotton 
from  the  plug  of  the  bottle  in  which  it  has  been  sterilized. 

The  skin  of  the  breast  is  carefully  disinfected ;  the  breast  is  then  grasped 
and  lifted  well  up  from  the  chest,  while  the  needle  with  the  salt  solution  flowing 
is  thrust  into  the  cellular  tissue  well  under  the  glandular  substance.  The  bottle 
is  elevated  six  feet  above  the  patient  in  order  to  give  suflicient  hydrostatic 
pressure  to  force  the  fluid  into  the  tissues.  As  a  rule  it  requires  about  twenty 
minutes  to  infuse  from  700  to  1,000  cubic  centimeters  of  the  solution  under 
both  breasts.  If  the  patient's  symptoms  are  urgent,  both  breasts  are  infused 
simultaneously.  As  the  infusion  proceeds  the  gland  becomes  greatly  distended, 
and  not  infrequently  the  salt  solution  spurts  from  the  nipple  in  a  fine  jet. 

At  the  completion  of  the  operation  a  piece  of  adhesive  plaster  must  be 
placed  over  the  point  of  puncture  to  prevent  a  reflux  of  some  of  the  injected 
fluid. 

In  many  cases  the  relief  is  so  great  that  the  patient  is  made  comparatively 
comfortable  at  once  and  does  not  even  complain  of  thirst. 

In  about  fifty  cases  in  which  I  have  employed  this  form  of  repletion  of  the 
circulation  there  has  not  been  the  slightest  ill  effect  in  the  way  of  local  inflam- 
mation about  the  breasts. 

Peculiarities  of  the  Pulse. — As  the  pulse  affords  one  of  the  most  important 
indications  of  the  patient's  condition,  any  deviation  from  the  normal  should  be 
noted  at  once  and  watched  l)y  the  surgeon  with  unusual  anx-iety.  The  chief 
value  of  the  pulse  is  barometrical,  as  it  were,  giving  an  early  indication  of  ap- 
proaching trouble.  In  order  that  the  pulse  may  act  as  a  guide  in  forming  an 
intelligent  opinion  of  the  case,  a  previous  observation  as  to  its  natural  character 
is  essential.  If  the  pulse  is  already  quickened  before  the  operation,  ranging 
between  100  and  130  or  even  higher,  a  simple  steady  acceleration  may  be  prop- 
erly regarded  as  favorable  rather  than  unfavorable,  as  this  is  to  be  expected. 

When  the  operation  is  prolonged  and  exhausting  the  pulse  rate  may  be  in- 


72 


COMPLICATIONS   AKISIXG    AFTER    ABDOMINAL   OPERATIONS. 


creased  20  or  30  beats,  and  maj  persist  so  for  some  hours,  or  even  one  or  two 
days,  witliout  causing  anxiety,  providing  it  maintains  its  strength,  ^'olume,  and 
rhythm.  One  of  the  surest  signs  of  reaction,  however,  is  the  gradual  decrease 
in  the  pulse-rate.  There  is  always  cause  for  anxiety  when  a  pulse,  previously 
regular  and  quiet  and  but  little  quickened,  begins  after  twelve  hours  or  more  to 
go  up,  rising  to  120,  then  130  or  l-lO  beats  per  minute,  at  the  same  time  becom- 
ing weaker.  If  in  conjunction  with  this  there  is  a  rise  of  temperature  and  the 
patient  assumes  a  distressed  look,  complains  of  pain,  is  nauseated  and  vomits 
occasionally,  and  the  abdomen  is  tympanitic,  septic  infection  may  exist.  It  is, 
however,  a  mistake  to  consider  even  the  widest  variation  of  the  j^ulse  rate  as 
indicating  in  itself  a  necessary  fatal  result. 


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Temperature Pulse 


Fig.  327. — Chart  showing  Convalescence  Complicated  by  a  High  Pulse  Rate,  followed  by  Reoovery. 

Operation:  cystectomy  for  multilocular  ovarian  cyst,  be<(un  under  eocain ;  e\ten.sive  adhesions,  and  hem- 
orrhage ;  ]Tulse  counted  on  table  200  per  iiiinutc.  Temperature  caused  probably  by  drain  and  stitch  ab- 
scesses.    No.  3307 

I  have  repeatedly  seen  patients  recover  whose  pulse  rate  was  as  high  as  140 
or  1.50  for  some  hours ;  in  one  instance  the  pulse  ranged  between  150  and  162 
for  three  days,  after  which  the  patient  made  an  uninterrupted  recovery. 


YARIATIOXS    IN    TEMPERATURE.  YS 

I  removed  an  ovarian  cjst  from  a  feeble  old  woman  whose  pnlse  went  up  to 
210  during  the  operation,  and  one  of  my  residents,  by  carefully  counting  the 
cardiac  impulse  over  the  pericardium,  made  it  at  one  time  240  per  minute,  and 
yet  she  made  a  good  recovery.     (See  chart,  Fig.  327.) 

An  intermittent  pulse  is  sometimes  observed  during  convalescence  when  it 
has  been  raj^id  immediately  after  operation  ;  indeed,  an  intermittent  pulse  occa- 
sionally occurs  after  operation  without  apparent  cause.  A  markedly  intermit- 
tent pulse  is  also  noted  in  the  latter  stages  of  septic  infection,  and  is  always  a 
cause  for  grave  apprehension. 

An  abnormally  slow  pulse  (bradycardia)  is  occasionally  noticed,  l)ut  it  usu- 
ally exists  also  before  operation.  I  had  a  patient  who  recovered  with  a  pulse 
rate  of  30  per  minute  after  eholecystotomy,  but  this  had  been  the  normal  rate 
through  life. 

Variations  in  Temperature. — Subnormal  temperature  is  indicative  of  pro- 
found depression  arising  from  shock,  hemorrhage,  or  the  gradual  retrogression 
of  the  vital  functions  preceding  death.  The  temperature  may  fall  slightly  below 
normal  during  or  immediately  after  an  operation  from  the  refrigerant  depressing 
effect  of  the  anesthetic,  especially  if  ether  has  been  employed,  but  quickly 
returns  or  rises  even  above  the  normal  upon  the  application  of  external 
heat. 

A  sudden  fall  of  temperature  after  the  patient  has  recovered  from  the  first 
effects  of  an  operation,  associated  with  an  increase  in  the  pulse  rate,  is  one  of 
the  signs  of  hemorrhage.  The  gradual  depression  of  temperature  preceding 
natural  death  is  usually  coincident  with  failure  in  all  the  other  vital  functions, 
and  is  different  from  the  rapid  fall  from  hemorrhage  or  severe  shock. 

Some  elevation  of  temperature,  known  as  simple  wound  fever,  is  observed  in 
almost  all  cases,  even  ^v•llere  the  recovery  is  otherwise  perfectly  normal.  This 
need  occasion  no  alarm,  although  calling  for  increased  watchfulness. 

The  composite  temperature  charts  in  Chapter  XXI  demonstrate  the  normal 
febrile  reaction  attending  the  healing  of  abdominal  wounds. 

Quite  frequently  a  considerable  elevation  of  temperature  occurs,  extend- 
ing over  several  days,  and  then  subsides  without  giving  any  sign  of  its 
cause. 

So  far  as  the  progress  of  these  cases  is  concerned  they  may  be  considered 
normal,  yet  since  we  can  not  reconcile  this  abnormal  elevation  of  temperature, 
extending  over  several  days,  with  a  perfect  convalescence  in  a  surgical  sense,  we 
are  constrained  for  tlie  present  to  attribute  it  to  the  effects  of  infection,  for  un- 
doubtedly mild  grades  of  infection  can  be  combated  by  the  phagocytic  action  of 
the  leucocytes  and  the  germicidal  effects  of  the  blood  serum  without  any  other 
signs  than  tliose  manifested  by  these  variations  of  temperature. 

Even  local  su])puration,  deep  in  the  abdominal  wall  or  about  the  stuni]>  of 
an  ovarian  cyst  or  the  cervix,  may  occur  and  never  l)e  definitely  located,  the 
accunmlations  of  pus  being  gradually  absorbed. 

Looking  at  these  abnormal  temperatures  from  this  standpoint,  the  gyne- 
cologist must  feel  anxious  about  his  case  until  the  normal  curve  is  reached. 


74:  COMPLICATIONS   ARISING    AFTER   ABDOMINAL    OPERATIONS. 

When  malaria  is  prevalent,  or  a  patient  comes  from  a  locality  in  which  it  is 
endemic,  a  sudden  rise  of  temperature  should  at  once  call  for  a  blood  examina- 
tion, and  the  surgeon  may  be  relieved  of  grave  anxiety  by  finding  the  Plas- 
modium m  a  1  a  r  i  ae  present. 

During  August  and  December,  1896,  my  associate,  Dr.  W.  W.  Russell, 
observed  several  of  these  cases  (see  Johns  Ilopk.  Hasp.  Bui.,  I^ov.,  Dec. 
1896). 

In  one  instance  the  patient  had  been  operated  upon  in  the  hospital  one  year 
previously  for  a  large  pelvic  abscess,  and  a  quantity  of  pus  was  evacuated  by 
vaginal  incision  and  drainage  ;  she  remained  in  perfect  health  until  two  weeks 
before  the  second  admission,  when  she  began  again  to  feel  miserable  ;  in  a  few 
days  severe  chills  came  on,  succeeded  by  headache,  backache,  and  high  fever. 

Feeling  sure  that  there  was  a  return  of  her  former  malady,  she  hurried  at 
once  to  the  hospital.  A  vaginal  examination  revealed  some  induration  at  the 
base  of  the  broad  ligament,  but  there  was  no  sign  of  any  purulent  collection. 

She  was  then  put  to  bed  and  watched  for  several  days,  when  a  blood  exam- 
ination was  made  and  the  plasm  odium  found  and  the  diagnosis  of  malaria  made 
(see  malarial  chart). 

By  keeping  in  mind  tlie  possibility  of  malaria  as  the  cause  of  high  tempera- 
ture grave  anxiety  and  even  serious  mistakes  may  be  avoided.  An  instance  of 
a  mistake  of  this  kind  is  that  of  a  gynecologist  who  performed  salpingo- 
oophorectomy  in  the  belief  that  the  adherent  appendages  that  he  removed  were 
the  cause  of  the  periodical  rise  in  temperature.  A  subsequent  examination  of 
the  blood  revealed  the  plasmodium,  and  a  course  of  quinin  speedily  relieved  the 
symptoms. 

Occasionally  the  most  unaccounta])le  rises  of  temperature  will  occur  during 
the  convalescence  of  an  abdominal  section  case.  When  there  is  a  definite  peri- 
odicity of  these  rises,  or  a  slight  diurnal  variation  like  that  seen  in  septic  cases, 
some  point  of  infection  will  usually  be  discovered  to  account  for  the  abnormal 
temperature. 

In  rare  cases  the  variations  in  temperature  follow  no  law,  rising  to  an  alarm- 
ingly high  point  one  day  and  then  abruptly  falling  to  normal,  where  it  may 
remain  for  a  variable  length  of  time  and  again  show  the  same  excursus.  The 
patient's  general  condition  is  usually  good,  and  in  no  way  corresponds  with  the 
temperature  ;  she  has  no  accompanying  chills  or  sweating ;  a  careful  physical 
examination  and  microscopic  examination  of  the  blood  fails  to  reveal  any  cause 
for  the  thermal  disturbance.  On  careful  review  of  the  higtory  of  such  a  case  a 
marked  hysteric  temperament  may  be  discovered,  which  may  account  for  the 
unusual  symptoms  ;  such  a  diagnosis,  however,  should  only  be  accepted  as  a  last 
resort  after  the  most  careful  exclusion  of  every  other  possible  source  ;  it  is  in 
just  such  cases  that  the  greatest  injustice  is  sometimes  done  the  patient. 

I  once  oi^erated  upon  a  young  woman  of  neurotic  temperament  for  extensive 
suppuration  of  the  pelvic  organs.  The  convalescence  progressed  smoothly,  the 
temperature  reaching  normal  on  the  seventh  day  after  operation,  and  continu- 
ing so  until  the  twelfth  day  ;  then  it  suddenly  rose,  between  eight  and  eleven 


VOMITIXG. 


75 


o'clock  in  the  morning,  to  105-5°  F.  (40-8°  C),  and  remained  at  this  point  until 
the  evening,  when  it  fell  abruptly  to  normal.  Xo  further  disturbance  was 
noted  for  six  days,  when  again  the  same  phenomenon  occurred.  During  this 
time  nothing  could  be  detected  to  account  for  the  rise  in  temperature,  and  it 
was  attributed  to  hysteria.  Two  days  later  the  temperature  again  rose  to  105°  F. 
(40-5°  C),  and  for  the  next  nine  days  showed  a  typical  septic  chart,  when  it 
again  reached  the  normal  and  continued  so  for  five  days,  and  again  rose  to 
102°  F.  (38-9°  C),  dropped  to  normal,  and  the  next  day  made  the  highest  rise 
of  any  time  during  the  convalescence,  reaching  106-5°  F.  (41-5°  C.)  The  patient 
complained  of  chills  and  sweating  occasionally,  but  otherwise  showed  no  ill 
effects  from  this  hyperpyrexia.     For  a  number  of  days  the  chart  indicated  sep- 


SEPT. 

OCT. 

DAY     OF 
MONTH 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

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120 
110 
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Puise 


I'lG.  328.— NoKMAL   Convalescence   Intebiupted   by   Periodical    Ki.«es   of   TEMrERATiUE    die   to   the 
Pkesence  of  the  Plasmodium  Malari.e.     No.  4618. 


sis,  and  yet  repeated  examinations  failed  to  reveal  its  presence.  Since  the  pa- 
tient's return  home  she  has  had  similar  attacks,  and  it  has  now  been  more  than 
two  years  since  her  operation  and  she  enjoys  fairly  good  health. 

Vomiting.— Xausea  and  vomiting  follow  the  administration  of  an  anesthetic 
in  the  great  majority  of  cases  where  the  operation  is  prolonged,  but  vomiting  can 
only  be  considered  a  complication  wlien  it  is  persistent  or  excessive. 

The  personal  peculiarities  and  idiosyncrasies  of  a  patient  are  an  important 
factor  in  the  case,  and  should  be  inquired  into  before  the  operation.  Patients 
frequently  volunteer  the  information  that  they  dread  the  anesthetic  on  account 
of  an  irrital)le  stomach  or  a  tendency  to  excessive  nausea  discovered  in  some 
former  experience. 


Y6  COMPLICATIONS   ARISING    AFTER    ABDOMINAL   OPERATIONS. 

Yomiting  may  invariably  follow  the  ingestion  of  liquids  or  food  for  three  or 
four  days  after  an  operation ;  indeed,  the  nausea  may  be  so  great  as  to  cause 
vomiting  at  the  mere  sight  of  food.  When  this  condition  is  associated  with  in- 
crease of  pulse  rate,  elevation  of  temperature,  tympanites,  and  severe  intermit- 
tent abdominal  pain,  it  may  be  accepted  as  a  sign  of  peritonitis.  In  this  case 
the  vomiting  becomes  more  frequent  and  retching  in  character,  the  ejecta  con- 
sisting of  a  little  yellow  or  black  bile,  expelled  in  small  quantities.  When 
excessive  emesis  is  associated  with  severe  intermittent  pains  and  a  failing  pulse, 
with  but  slight  elevation  of  temperature,  it  points  strongly  to  intestinal  obstruc- 
tion, when  the  vomited  matter  may  soon  become  feculent  in  odor. 

Sometimes  the  appearance  of  the  ejecta  and  the  sev^ere  pain  in  the  epigas- 
trium suggest  gastric  ulcer,  gastritis,  or  some  other  affection  of  the  stomach ; 
under  these  circumstances  the  history  aids  in  establishing  or  disjjroviug  the 
supposition. 

Treatment . — The  stomach  must  have  absolute  rest  so  long  as  it  is  in  an  irri- 
table condition,  and  nutrition  must  be  maintained  largely  by  rectal  alimentation. 
Internal  medication  is  usually  of  little  service,  although  occasionally  limewater 
in  small  quantities  seems  to  allay  the  excessive  irritability.  A  few  drops  of  the 
spirits  of  chloroform  may  be  given  at  frequent  intervals ;  cocain,  2-per-cent 
solution,  may  be  given  in  10  to  20  minim  doses ;  or  bismuth  subnitrate  or  mor- 
phin  in  small  doses  is  also  valuable.  Iced  champagne  in  2  or  3  drachm  doses  fre- 
quently has  a  soothing  effect.  Two  or  three  drops  of  tincture  of  capsicum  in  a 
teaspoonful  of  hot  water  is  often  valuable.  If  the  bowels  have  not  l)een 
moved,  relief  is  often  instantaneous  upon  a  thorough  evacuation. 

In  intractable  cases  the  greatest  relief  frequently  follows  the  washing 
out  of  the  stomach  with  a  weak  boric-acid  solution,  and  after  lavage  two 
or  three  times  the  vomiting  will  often  disappear  entirely. 

For  this  reason  I  always  resort  to  lavage  when  doubtful  whether  or  not  the 
vomiting  is  a  sign  of  an  obscure  peritonitis  or  aii  ileus,  and  in  several  instances 
it  has  seemed  even  to  save  the  patient's  life.  Its  happy  effect  is  well  illustrated 
by  case  K.  B.,  No.  4828.  Operation,  ISTov.  23,  1896.  A  hysteromyomectomy 
was  performed  for  an  enormous  myoma,  entirely  subperitoneal.  All  went  well 
until  the  sixth  day,  when  the  patient  complained  of  intense  epigastric  pains, 
kept  crying  out  and  vomiting  violently,  and  had  the  appearance  of  a  woman  in 
extreme  collapse.  It  was  curious  to  note  that  although  she  was  an  ignorant 
woman  she  persistently  declared  that  her  bowels  were  closed,  and  if  she  did  not 
get  a  passage  through  she  would  shortly  die.  I  saw  her  in  this  condition  on 
the  following  day  and  ordered  lavage,  which  gave  immediate  and  permanent 
relief. 

A  hot-water  bag,  ice  bag,  or  a  weak  mustard  plaster,  applied  to  the  epigas- 
trium, usually  renders  the  patient  more  comfortable,  and  may  bring  entire  relief 
from  the  nausea. 

As  a  rule,  it  is  best  to  withhold  all  food  by  the  mouth  until  there  are  no 
more  active  manifestations  of  the  nausea.  Nutrient  enemata,  if  properly  pre- 
pared, are  easily  assimilated,  and  may  be  relied  upon  exclusively  for  a  few  days. 


TYMPANITES.  77 

Among  the  best  formulae  are  the  following : 

1.  One  egg. 

A  little  table  salt. 

Peptonized  milk,  60  to  90  cubic  centimeters  (2  to  3  ounces). 

Brandy,  30  cubic  centimeters  ;  or, 

2.  The  whites  of  two  eggs. 

Peptonized  milk,  180  to  200  cubic  centimeters. 

To  allay  excessive  thirst,  a  half  pint  or  a  pint  of  water  injected  high  up  into 
the  bowel  is  efficacious. 

Dr.  E.  C.  Dudley,  of  Chicago,  recommends  enemata  of  beef  tea, 
which  I  have  used  with  great  satisfaction,  as  they  serve  the  double  purpose,  if 
they  are  retained,  of  furnishing  food  and  relieving  thirst ;  and  if  they  are  ex- 
pelled, an  early  evacuation  of  the  bowels  may  be  secured. 

The  food  in  these  cases  when  first  given  by  the  mouth  must  be  light  and 
digestible,  and  given  in  small  quantities  at  frequent  intervals.  Albumen,  as 
prepared  in  Chapter  XXI,  is  the  least  irritating  form  of  nutriment.  Meat 
jellies,  light  broths,  or  koumiss  are  best  retained  as  soon  as  the  condition  of  the 
stomach  begins  to  improve. 

Tympanites. — Excessive  tympanites  is  one  of  the  most  distressing  complica- 
tions following  celiotomy.  The  abdomen  becomes  greatly  distended  and  often 
markedly  sensitive,  and  the  upward  pressure  on  the  stomach  and  diaphragm 
interferes  \vith  digestion  and  impedes  respiration  to  such  an  extent  as  to  cause 
great  discomfort.  I  have  seen  two  instances  where  death  seemed  to  have  been 
due  to  the  paralysis  of  the  diaphragm  caused  by  an  excessive  tympanites,  as  the 
autopsies  revealed  no  other  possible  cause.  Palpitation  of  the  heart  and  dis- 
turbed rhythm  are  frequently  due  to  this  intestinal  distenton.  Tympanites,  like 
the  variation  in  pulse  rate  and  temperature,  may  be  without  serious  significance, 
due  simply  to  intestinal  atony  or  constipation,  which  is  promptly  relieved  by 
appropriate  measures.  If  it  is  associated  with  increasing  pulse  rate,  fever,  con- 
stipation, and  vomiting,  it  is  a  symptom  of  peritonitis. 

Treatment . — The  application  of  turpentine  stupes  to  the  abdomen  is  one 
of  the  best  of  tlie  mild  remedies  often  effectual  in  relieving  the  condition.  The 
stupe  is  made  by  w^ringing  a  broad  piece  of  flannel  out  of  hot  water  containing 
turpentine  in  the  proportion  of  60  cubic  centimeters  to  the  liter  (1  ounce  to  the 
pint).  The  stupes  must  not  be  left  on  too  long,  or  be  too  frequently  repeated, 
or  they  M'ill  blister  the  skin. 

The  introduction  of  a  rectal  tube  high  up  into  the  lower  bowel 
permits  the  escape  of  flatus  and  often  affords  relief  at  once.  When  there  is 
an  excessive  accumulation  of  gas  it  is  advisable  to  leave  the  tube  in  the  rec- 
tum for  some  hours.  To  facilitate  the  passage  of  the  tube  the  index  finger 
should  be  well  oiled  and  introduced  as  far  up  as  possible  to  serve  as  a  guide  for 
the  end  of  the  tube  as  it  is  pushed  through  the  ampulla  into  the  upper  bowel 
where  the  gas  is  accumulated.  If  this  is  not  done  the  tube  will  be  almost  cer- 
tain to  coil  up  in  the  ampulla  without  reaching  the  upper  rectum  at  all. 

Hoffman's  anodyne,  in  the  dose  of  twenty  minims  to  a  drachm,  given  in 


Y8  COMPLICATIONS   AEISING    AFTER   ABDOMINAL   OPERATIONS. 

cracked  ice,  is  a  good  internal  remedy.  Five  drops  of  turpentine  in  emulsion  or  on 
loaf  sugar  is  also  of  value,  stimulating  and  assisting  in  the  expulsion  of  the  flatus. 

The  evacuation  of  the  bowel  by  an  active  purgative — 
such  as  magnesium  sulphate,  citrate  of  magnesia,  or  a  pill  of  aloin,  strychnin, 
and  belladonna,  followed  by  repeated  enemata  of  oil  or  soapsuds — is  the  best  of 
all  means  of  permanently  relieving  tympany,  and  should  be  resorted  to  at  once 
if  the  mild  measures  fail  after  a  brief  trial. 

One  of  the  best  remedies  for  a  distressing  tympany  is  the  light  applica- 
tion of  the  Paquelin  cautery.  The  platinum  tip  should  be  heated 
to  dull  redness  and  lightly  drawn  over  the  abdomen,  only  touching  the  top  of 
the  short  hairs,  and  not  actually  coming  in  contact  with  the  epidermis.  The 
manipulation  of  the  cautery  requires  some  little  skill,  or  deep  burns  may  be  pro- 
duced. It  is  best  to  practice  the  movement  with  the  cold  point  on  one's  own 
arm  before  trying  it  upon  the  patient.  When  the  entire  abdomen  has  been 
gone  over  in  this  way  the  patient  is  usually  greatly  relieved,  and  begins  at  once 
to  expel  great  volumes  of  flatus.  The  relief  has  been  so  great  in  some  cases 
that  I  have  had  patients  who  were  almost  paralyzed  with  fear  at  the  sight  of 
the  red-hot  tip  during  the  first  application  request  a  repetition  of  the  treatment 
on  the  slightest  return  of  the  tympany. 

Where  there  is  reason  to  anticipate  a  tympanitic  condition  of  the  bowel  on 
account  of  extensive  injury  to  its  peritoneal  coat  or  on  account  of  inefiicient 
evacuation  of  the  bowel  previous  to  operation,  the  cautery  can  be  used  with 
good  effect  on  the  slightest  indication  of  distention.  In  these  cases  it  acts  as 
a  prophylactic. 

In  an  extreme  case  I  know  of  no  plan  so  good  as  that  of  Dr.  L.  M, 
Sweetnam,  of  Toronto,  which  consists  in  the  postural  treatment  of  tympany  by 
putting  the  jjatient  in  the  knee-breast  posture  and  introducing  a  rectal  tube. 
As  soon  as  the  tube  passes  beyond  the  utero- sacral  ligaments  volumes  of  gas 
begin  to  escape.  One  of  my  patients  was  desperately  ill  with  tympany — the 
barrel-like  abdomen  as  tense  as  a  drum,  and  the  pelvis  was  so  choked  with  dis- 
tended intestines  that  the  rectal  tube  could  not  be  passed.  I  gave  her  com- 
plete relief  by  putting  her  under  chloroform  and  introducing,  in  the  knee- 
breast  posture,  one  of  my  long  rectal  specula ;  the  bowel  was  collapsed  until  the 
speculum  reached  the  sigmoid  flexure,  when  the  gas  began  to  escape  freely,  and 
she  recovered. 

Excessive  Pain. — The  surgeon,  and  especially  the  family,  are  often  unneces- 
sarily fearful  on  account  of  the  excessive  suffering  of  the  patient  after  an 
abdominal  operation.  The  pain  is  usually  referred  to  the  lower  abdomen,  where 
it  is  constant  and  so  severe  as  to  seem  almost  unendurable.  Highly  sensitive  or 
nervous  women  will  oftener  complain  in  this  way,  while  others  of  a  phlegmatic 
temperament,  or  who  are  accustomed  to  exercising  self-control,  suppress  all 
manifestations  of  pain  and  only  complain  when  questioned. 

The  simplest  al^dominal  operations  may  be  followed  by  the  severest  pain, 
while  other  cases,  where  extensive  adhesions  to  adjacent  organs  have  been  sepa- 
rated, cause  comparatively  little  or  even  no  suffering. 


PERITOXITIS.  79 

In  the  absence  of  other  untoward  symptoms  there  is  no  occasion  for  alarm, 
as  the  pain  usually  subsides  in  from  twenty -four  to  forty-eight  hours,  and  the 
patient  suffers  but  little  afterward.  Women  addicted  to  the  use  of  morphin 
complain  most  bitterly  and  are  the  longest  in  becoming  quiet  after  operation. 
If  sedatives  are  persistently  withheld  these  patients  become  exhausted  in  one  or 
two  days,  and  are  not  so  importunate  in  their  demands  for  the  drug,  and  al- 
though they  may  say  they  have  had  absolutely  no  sleep,  an  observant  nurse  will 
have  noted  many  short  naps  aggregating  in  all  sufficient  rest  in  twenty -four 
liours.  I  know  of  no  better  method  of  breaking  the  common  morphin  habit 
than  the  absolute  prohibition  of  anodynes  in  any  form  during  their  convales- 
cence following  operation.  The  suffering  for  the  first  two  or  three  days  is 
undeniably  of  the  severest  character,  but  the  moral  effect  produced  by  triumph- 
ing over  real  pain,  and  the  realization  that  it  can  be  accomplished  without  resort 
to  morphin,  are  of  the  greatest  value  in  restoring  the  moral  stamina  of  the 
patient.  After  having  gone  through  such  a  struggle  the  patient  will  rarely 
return  to  its  use  if  she  has  any  moral  character  left  to  work  upon. 

In  ordinary  cases  I  do  not  object  to  the  use  of  one  or  two  hypodermics  of 
morphin  in  the  first  twenty -four  hours,  indeed  it  is  better  to  use  it,  but  no  prac- 
tice is  more  pernicious  than  the  repeated  administration  of  sedatives  for  the 
relief  of  pain  for  several  days  following  abdominal  operations.  The  general 
tone  of  the  patients  who  have  withstood  the  pain  without  anod^mes  is  far  better 
at  the  end  of  a  week  than  that  of  those  who  have  been  relieved  by  morphin. 

The  severe  pain  complained  of  by  neurotic  or  acutely  sensitive  women  must 
be  carefully  differentiated  from  the  pain  of  peritonitis,  which  is  most  severe  on 
the  second,  third,  or  fourth  day  after  operation,  and  is  intermittent  in  character, 
associated  with  tympanites,  elevated  temperature,  quickened  pulse,  and  a  bad 
facial  expression  ;  here,  too,  morphin  should  be  withheld,  as  it  dulls  the  patient's 
mind,  locks  up  the  secretions,  blunts  the  sensations,  and  so  tends  to  mask  the 
symptoms  at  a  critical  period. 

Peritonitis. — If  we  accept  the  views  of  Grawitz,  Klemperer,  and  others  con- 
cerning the  pathology  of  peritonitis,  we  class  all  forms  together  as  septic  or 
infectious. 

A  number  of  observers,  however,  maintain,  from  the  standpoint  of  experi- 
mental as  well  as  of  clinical  observation,  that  there  exists  a  simple,  post-opera- 
tive, traumatic  peritonitis  without  infection.  This  view  would  seem 
to  be  supported  by  the  common  surgical  experience  that  although  cultures 
taken  throughout  the  course  and  at  the  end  of  an  operation  frequently  show  no 
growths  and  therefore  the  absence  of  an  infection,  yet  for  the  first  two  or  three 
days  after  an  operation  the  patient  may  exhibit  many  of  the  symptoms  of 
peritonitis. 

The  experimental  researches  of  Pawlowsky  upon  the  etiology  of  peritonitis 
would  seem  also  to  confirm  this  view ;  he  injected  various  chemicals  into  the 
peritoneal  cavity  of  animals  and  found  that  they  produced  a  "  simple  inflam- 
mation.'" 

In  several  instances  where  I  have  been  compelled  to  reopen  the  abdomen 


80  COMPLICATIONS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 

soon  after  the  original  operation  to  relieve  an  obstructed  bowel  I  have  found 
extensive  union  between  adjacent  peritoneal  surfaces ;  these  cases  failed  to 
show  any  kind  of  micro-organisms  in  the  peritoneal  cavity,  and  yet  the  evidences 
of  the  pouring  out  of  a  plastic  lymph  with  the  subsequent  formation  of  ad- 
hesions were  abundant. 

The  scientific  pathologist  seriously  questions  the  propriety  of  denominating 
as  forms  of  true  peritoneal  inflammation  those  processes  which  are  simply 
associated  with  the  repair  of  the  injured  tissues,  and  are  thus  of  necessity  purely 
localized  at  the  seat  of  the  injury. 

I  think,  however,  that  for  the  more  practical  purposes  of  the  surgeon  it  will 
be  well  for  the  present  to  preserve  the  customary  nomenclature  without  ex- 
pressing a  definite  judgment  as  to  the  strictly  scientific  question  involved,  for  in 
the  first  place  it  behooves  the  surgeon  to  be  keenly  on  the  alert  to  detect  peri- 
tonitis and  everything  that  simulates  it,  and,  in  the  second  place,  it  is  equally 
certain  that  if  the  plastic  forms  are  not  themselves  true  inflammations  they  do 
unquestionably  often  form  the  basis  of  an  inflammation. 

Traumatic  or  Plastic  Peritonitis. — The  so-called  traumatic  or  plastic  peri- 
tonitis is  a  regenerative  process,  and  occurs  to  some  degree  in  every  case  in 
which  the  abdomen  is  opened ;  it  is  slight  and  circumscribed  after  simple  opera- 
tion, and  extensive  when  wide  areas  of  adhesion  have  been  separated,  as  in  the 
enucleation  of  adherent  tubal  and  ovarian  tumors.  The  wide  area  of  cellular 
tissue  exposed  in  some  cases  gives  rise  to  serous  oozing,  and  the  plastic  lymph 
serves  to  agglutinate  adjacent  structures  to  the  raw  areas,  which  become  vascu- 
larized, and  finally  converted  into  fibrous  tissue.  A  traumatic  "  peritonitis " 
may  also  be  induced  by  prolonged  exposure  or  rough  manipulation  of  the  ab- 
dominal viscera  without  taking  away  the  peritoneal  covering.  The  character  of 
the  adhesions  formed  varies ;  sometimes  they  are  flat  and  dense  and  can  only 
be  liberated  by  tearing  the  bowel  or  cutting  away  the  adherent  surfaces ;  or 
they  are  long  and  weblike  or  velamentous,  and  can  be  freed  without  difiiculty. 
After  some  months  the  most  extensive  adhesions  may  disappear  spontaneously 
by  absorption.  I  have  opened  the  abdomen  a  second  time  in  cases  where  the 
adhesions  were  almost  universal  at  the  time  of  the  flrst  operation,  and  found 
only  a  few  delicate  bands  remaining. 

S  y  m  p  t  o  ms . — In  the  milder  forms  there  are  no  symptoms  whatever.  The 
symptoms  of  the  more  aggravated  forms  are  vomiting,  severe  pain  in  the  lower 
abdomen,  tympanites,  tenderness  on  pressure,  accelerated  pulse,  and  elevated  tem- 
perature, rising  at  first  to  99°,  tlien  to  100°,  or  even  101°.  The  pulse  is  usually 
only  slightly  quickened  and  remains  full  in  volume,  and  the  patient  has  a  good 
facial  expression,  lacking  the  pale,  drawn  appearance  characteristic  of  sepsis. 
Vomiting  is  less  frequent  and  not  so  persistent  and  so  retching  in  character  as 
in  septic  peritonitis.  The  ejecta  consist  of  the  contents  of  the  stomach,  but 
the  vomiting  is  not,  as  a  rule,  of  the  violent  biliary  character  seen  in  septic 
peritonitis.  Traumatic  peritonitis  rarely  becomes  general,  although  the  extreme 
tympany  and  general  tenderness  over  the  abdomen  often  lead  to  such  an 
inference. 


TKAUMATIC    OR    PLASTIC    PERITOXITIS.  81 

Dangerous  symj^toms  may  arise  from  pressure  of  the  distended  intestines 
on  the  diaphragm,  interfering  with  respiration,  or  from  ileus,  or,  later,  from 
strangulation  of  the  bowel  bv  bands  of  adhesions. 

In  the  usual  course  of  simple  plastic  peritonitis,  in  from  two  to  four  days 
after  the  oj)eration  the  t^-mpanites  disappears,  the  pain  suljsides,  the  temper- 
ature gradually  falls,  the  pulse  rate  decreases,  and  convalescence  becomes  estab- 
lished. While  the  convalescence  usually  proceeds  in  this  manner,  if  the  fluid 
is  not  promptly  absorbed  another  outcome  is  possible ;  the  few  germs  which 
always  get  into  the  peritoneum,  even  in  the  most  aseptically  conducted  oper- 
ations, find  in  the  stagnating  fluid  a  rich  nutriment  under  precisely  the  proper 
conditions  of  temperature  for  a  rapid  multiplication,  and  in  this  way  a  septic 
peritonitis  may  be  produced,  which  would  never  have  arisen  in  a  dry  peritoneum. 

Treatment . — P  rophylaxis  plays  an  important  role  in  the  treatment 
of  traumatic  peritonitis.  At  the  operation  the  intestines  must  be  exposed  and 
handled  as  little  as  possible,  and  kejjt  carefully  protected  with  gauze.  JSTo 
other  solution  than  the  normal  salt  solution  should  come  into  contact  with  the 
peritoneum.  Where  denudation  is  necessary  its  extent  should  be  as  limited  as 
possible,  and  M'henever  possible  flaps  of  peritoneum  should  be  left  to  cover  up 
the  denuded  areas.  The  amount  of  exudation  will  be  lessened  by  protecting  the 
denuded  areas  and  by  checking  all  hemorrhage  before  closure. 

Free  purgation  is  the  sheet  anchor  in  the  treatment  of  traumatic  peritonitis, 
depleting  the  circulation  and  actively  remo^dng  the  fluids  within  the  peritoneum. 
If  the  stomach  is  not  too  unsettled,  a  hydragogue  purgative,  such  as  citrate  of 
magnesia  or  a  concentrated  solution  of  Epsom  salts,  should  be  given  every  hour 
until  the  bowels  are  freely  moved.  '  Sometimes,  even  with  considerable  nausea, 
these  purgatives  may  be  given  by  the  mouth,  and  instead  of  increasing  th-e 
nausea  will  often  allay  it.  Calomel  in  half -grain  doses  every  hour  until  two 
grains  are  administered,  followed  by  a  saline  cathartic,  acts  well  in  many  cases. 

If  the  irritability  of  the  stomach  is  so  great  as  to  preclude  the  administra- 
tion of  drugs  by  the  mouth,  the  evacuation  nmst  be  secured  by  enema,  begin- 
ning with  a  pint  of  warm  soapsuds  containing  three  or  four  ounces  of  sweet 
oil  or  one  drachm  of  spirits  of  tur])entine.  This  should  be  repeated  every  two 
or  three  hours  until  the  bowels  are  freely  moved  and  the  flatus  expelled. 

By  the  time  the  lower  bowel  is  thoroughly  evacuated  the  stomach  will  usu- 
ally be  settled  sufficiently  to  tolerate  medicine  by  the  mouth.  If  the  enema  is 
expelled  as  soon  as  it  is  injected,  the  rectal  tube  must  be  introduced  again,  this 
time  high  up  into  the  colon,  so  that  the  enema  may  be  thrown  at  once  into  the 
Mgmoid  flexure,  <jr  even  higher.  One  is  often  surprised,  notwithstanding  the 
free  evacuation  of  the  bowels  before  the  operation,  to  see  the  large  amount  of 
fecal  matter  passed  at  this  time. 

The  diet  should  consist  of  highly  nutritious  licpiid  food,  which  will  leave 
little  or  no  residuum  in  the  intestinal  canal  ;  plain  milk  should  tluMvfore  be  dis- 
carded. 

To  facilitate  thorough  digestion  and  to  allay  nausea  the  food  should  be  given 
in  small  (piantities  every  hour  or  two.  PejJtonized  milk,  beef  broth,  wine  whey, 
4C 


82  COMPLICATIONS   ARISING    AFTER    ABDOMINAL    OPERATIONS. 

and  mulled  wine  are  all  easily  assimilated.  Iced  champagne  or  soda  water  in. 
small  quantities  are  often  soothing  when  the  stomach  is  excessively  irritable. 
If  the  stomach  is  intolerant  to  foods,  rectal  alimentation  must  be  resorted  to 
according  to  the  method  described  on  page  77.  A  turpentine  stupe  or  a  hot- 
water  bag  applied  to  the  abdomen  is  useful  in  allaying  pain. 

Patients  sometimes  experience  the  greatest  relief  from  the  application  of 
iced  flannels  over  the  abdomen. 

Post-operative  Septic  Peritonitis. — This  form  of  peritonitis  is  invariably  pro- 
duced by  the  invasion  of  pyogenic  micro-organisms  into  the  peritoneal  cavity. 
It  is  due,  therefore,  to  a  localized  infection  extending  from  a  definite  point 
out  over  the  surrounding  peritoneum  until  it  is  either  checked  by  a  wall  of  in- 
testinal adhesions  or  until  it  has  invaded  the  entire  peritoneal  cavity.  The  con- 
ditions underlying  the  infection  of  the  peritoneum  are  the  same  as  those  under- 
lying the  infection  of  all  other  wounds. 

The  view  of  older  surgeons  that  the  peritoneum  was  especially  susceptible  to 
infection  has  been  disproved  by  many  clinical  and  exjterimental  observations  ; 
indeed,  we  have  now  so  far  reversed  this  opinion  that  we  consider  the  perito- 
neum one  of  the  most  resistant  of  all  the  organs  to  the  invasion  of  micro-organ- 
isms. We  know  also  that  we  are  constantly  testing  its  powers  of  resistance,  for 
in  spite  of  every  effort  we  rarely  exclude  all  infectious  germs  from  the  peritoneal 
cavity  during  an  operation. 

The  experiments  of  Pawlowsky,  Grawitz,  Welch,  Halsted,  Waterhouse,  and 
others  all  show  that  the  healthy  peritoneum  can  withstand,  without  the  least 
visible  reaction,  great  quantities  of  pyogenic  organisms  if  they  are  introduced 
suspended  in  a  fluid  culture  medium. 

Sanger  has  defined  three  important  conditions  concerned  in  infectious  pro- 
cesses:  first,  qualitative,  relating  to  the  pyogenic  properties 
of  the  infectious  germ;  second,  quantitative,  relating  to  the 
number  of  organisms  present;  and  third,  the  constitutional, 
referring  to  the  susceptibility  of  the  subject  to  infec- 
tion, 

Dr.  William  Welch  says:  "It  is  apparent  that  while  there  is  no  reason  to 
doubt  that  pyogenic  cocci  are  specific  agents  of  infection,  the  effects  which  they 
produce  depend  upon  a  variety  of  conditions,  such  as  the  source,  the  number, 
and  the  virulence  of  the  micrococci,  the  accompanying  toxic  substances,  the 
part  of  the  body  invaded,  the  readiness  of  absorption,  the  presence  of  foreign 
bodies  and  the  pathological  products,  the  general  state  of  the  patient,  and  the 
condition  and  handling  of  the  wounded  tissues." 

The  more  we  learn  of  infectious  processes  the  more  are  we  convinced  that 
the  vital  resistance  of  the  patient  plays  an  important,  if  not  the  greatest  part,  in 
the  resistance  to  infection.  If  a  patient  is  much  depressed  physically,  and  is 
subjected  to  an  abdominal  operation  in  which  there  is  extensive  traumatism 
to  the  peritoneum  attended  by  considerable  oozing,  the  chances  for  a  serious  in- 
fection are  much  increased.  To  the  individual  factor  of  vital  resistance  is  un- 
doubtedly ascribable  many  of  the  discrepancies  as  to  the  apparent  varying  degrees 


POST-OPERATIVE    SEPTIC    PERITONITIS.  83 

of  virulence  of  the  same  infection,  when  nnder  precisely  the  same  conditions 
one  patient  will  be  infected  and  another  escape. 

It  is  a  clinical  fact,  and  one  which  all  discriminating  physicians  have  learned 
to  value,  that  persons  suffering  from  pre-existing  chronic  cardiac,  renal,  or  he- 
patic disease  are  prone  to  be  carried  off  suddenly  by  intercurrent  acute  affections, 
which  it  is  now  recognized  are  due  to  pathogenic  micro-organisms.  If  these 
conditions  arise  spontaneously,  without  the  aid  of  traumatism  or  in  consequence 
of  a  surgical  procedure,  it  may  be  regarded  as  a  natural  sequence  for  infection 
to  take  place  under  like  circumstances  when,  as  a  result  of  surgical  operations, 
the  way  is  opened  for  the  entrance  into  the  body  of  pathogenic  bacteria ;  the 
gravity  of  the  infectious  process  will,  in  a  given  instance,  depend  upon  the 
degree  of  absence  of  resistance  to  infection  in  the  individual,  the  nature  of  the 
operation,  the  perfection  of  the  technique  employed,  and  the  virulence  of  the 
entering  micro-organisms. 

The  pathological  and  bacteriological  study  of  all  the  cases  of  peritonitis  which 
have  come  to  autopsy  in  the  Johns  Hopkins  Hospital  has  clearly  demonstrated 
the  greater  liability  to  the  invasion  of  bacteria  on  the  part  of  persons  subject  to 
chronic  diseases  of  one  or  several  of  the  important  viscera. 

It  is  well  established  that  the  streptococcus  pyogenes  is  the  most 
virulent  of  all  the  ordinary  micro-organisms,  and  its  introduction  or  escape  into 
the  peritoneal  cavity  is  one  of  the  most  dangerous  accidents  that  can  occur  in 
the  course  of  an  operation.  I  found  by  a  routine  examination  of  all  pelvic  ab- 
scesses that  the  streptococcus  was  rarely  present,  and  when  it  did  occur  the  use 
of  drainage  was  of  little  or  no  avail  m  resisting  a  further  invasion,  as  a  virulent 
infection  of  the  peritoneum  was  almost  invariably  fatal  whether  the  drain  was 
inserted  or  not. 

The  staphylococcus  aureus  under  favorable  conditions  may  also 
give  rise  to  an  extensive  serous  inflammation  and  septicemia.  In  the  live  cases 
of  post- operative  peritonitis  which  occurred  in  the  gynecological  department  of 
the  Johns  Hopkins  Hospital  in  1893  the  infecting  organism  was  the  staphy- 
lococcus  aureus. 

The  bacillus  coli  communis  under  favorable  conditions  is  capable  of 
producing  a  peritonitis,  although  its  role  in  this  capacity  has  been  (questioned. 
The  growth  of  the  bacillus  is  so  vigorous  that  it  would  appear  to  kill  the  less 
resistant  pyogenic  cocci,  which  are  consequently  not  found  by  the  time  the 
patient  is  operated  upon  or  on  the  autopsy  table. 

Other  organisms,  besides  the  simple  pyogenic  cocci,  are  capable  of  causing 
peritonitis.  Cases  have  been  reported  in  which  the  bacillus  pyocyaneus, 
the  bacillus  proteus,  bacillus  typhosus,  and  the  micrococcus 
lanceolatus  have  been  the  infecting  agents. 

The  gonococcus,  while  occasionally  found  in  purulent  collections  in  the  peri- 
toneum, seems  only  in  rare  instances  to  possess  the  power  of  exciting  an  active 
inflammation  of  the  serous  membranes.  In  many  lunulreds  of  bacteriological 
examinations  I  have  never  yet  been  al)le  to  demonstrate  this  micro-organism  as 
the  etiological  factor  in  the  production  of  septic  peritonitis.     In  one  case  which 


84  COMPLICATIOXS    ARISIXG    AFTER   ABDOMIXAL    OPERATIONS. 

came  under  luy  observation  a  pus  tube  Lad  been  ruptured  some  days  previous 
to  opei'ation,  giving  ample  opportunity  for  tlie  beginning  of  an  inflannnation. 
At  the  time  of  operation  tliere  was  only  the  slightest  local  pelvic  peritonitis, 
notwithstanding  the  fact  that  a  great  quantity  of  pus  containing  myriads  of 
gonococci  was  lying  free  in  the  pelvis.  The  patient  made  an  uninterrupted  re- 
covery without  even  the  usual  symptoms  of  traumatic  peritonitis. 

The  staphylococcus  alb  us,  under  favorable  circumstances,  may 
produce  a  local  peritonitis,  but  its  pyogenic  properties  are  slight. 

The  group  of  infectious  peritonitic  cases  may  be  further  sulxlivided,  de- 
pending upon  the  virulence  of  the  infection  and  the  resistance  of  the 
patient. 

The  most  fatal  of  all  forms  is  that  where  the  micro- 
organism multiplies  so  rapidly  and  its  toxic  products  are 
taken  up  so  quickly  1) y  the  blood  and  lymph  vessels  t li a t 
the  jjatient  is  overwhelmed  in  a  very  short  time  and  dies 
as  though  suffering  from  severe  shock.  In  these  cases  the 
local  reaction  is  slight,  and  there  may  be  but  little  evi- 
dence of  peritonitis,  the  symptoms  1) e i n g  almost  entirely 
constitutional.  The  peritoneum  in  these  cases  is  covered  with  a  thin  slimy 
or  viscid  exudate  of  fibrin,  which,  upon  microscopical  examination,  sliows  myriads 
of  micrococci. 

The  onset  of  the  symptoms  is  rapid,  the  pulse  showing  an  abrupt  rise,  and  tlie 
general  appearance  of  the  patient  becoming  mucli  worse.  The  temperature,  as 
a  rule,  only  rises  to  99°,  100°,  or  101°  F.  (37-2°,  37-8°,  38-3°  C),  but  it  may 
show  a  wide  excursus  above  the  normal. 

I  cite  two  cases  as  examples  of  this  fulminating  form  of  peritonitis,  in  botli 
of  which  streptococci  were  present.  Y.  W.  (3198).  The  patient  was  operated 
upon  Nov.  8,  1894,  for  multiple  myoraata  of  the  uterus.  The  tumor  was  large 
and  lay  in  an  oblique  direction  in  the  abdomen  from  the  right  ovarian  region  to 
the  spleen.  Tlie  operation  was  done  under  the  usual  precautions,  and  was  not 
especially  difficult.  The  time  of  operation  from  beginning  to  end  was  fifty -five 
minutes.  Practically  no  bleeding  occurred,  the  vessels  being  securely  clamped 
and  tied  as  the  operation  progressed.  The  uterus  was  amputated  just  above  the 
cervix,  and  the  uterine  cavity  appeared  normal.  The  stump  was  then  lightly 
drawn  together  with  catgut  sutures,  and  over  this  the  peritoneum  was  sutured. 
JSTo  blood  or  debris  remained  in  the  pelvic  cavity  at  the  completion  of  the  opera- 
tion, and  the  patient  left  the  operating  table  in  splendid  condition  and  quickly 
rallied  from  the  efl'ects  of  the  anesthetic. 

She  was  returned  to  the  ward  at  10  a.  m.,  and  by  six  o'clock  the  same  day 
her  temperature  had  reached  101°  F.  (38-3°  C),  and  her  pulse,  which  had 
ranged  between  80  and  90,  suddenly  ran  up  to  120  and  130  and  became  irregu- 
lar. Her  appearance  was  bad,  the  face  was  covered  with  cold  perspiration,  and 
the  expression  was  drawn. 

Under  strong  stimulation  in  the  way  of  rectal  enemata  and  whiskey  and 
strychnin,  the  patient  appeared  to  improve  a  little,  but  by  the  next  morning  the 


POST-OPERATIVE    SEPTIC    PERITONITIS.  85 

pulse  had  almost  disappeared.     The  abdomen  was  tympanitic  and  tender  to 
pressure. 

The  svmiDtoms  were  so  rapid  in  their  onset  that  the  possibility  of  a  secondary 
hemorrhage  was  seriously  discussed. 

At  eight  o'clock  the  patient  was  taken  to  the  operating  room  and  the  abdo- 
men reopened.  There  was  no  trace  of  hemorrhage.  As  soon  as  the  stitches 
were  removed  from  the  abdominal  wall  a  few  drops  of  thin,  yello\vish  pus  ex- 
uded. On  opening  the  abdomen,  the  intestines  and  parietal  peritoneum  were 
found  covered  with  a  very  thin  viscid  layer  of  fibrin. 

The  abdomen  was  irrigated  thoroughly  and  a  gauze  drain  inserted,  and  salt 
solution  was  infused  into  the  radial  artery. 

Patient  regained  consciousness,  but  died  within  an  hour.  Her  temperature 
in  the  early  morning  hours  reached  lo4-5°  F.  {4:(y'2°  C). 

Autopsy  ^o.  595.  Anatomical  diagnosis :  Laparotomy  wound  for  hystero- 
myomectomy ;  wound  infection ;  acute  fibrino-purulent  peritonitis ;  cloudy 
swelling  of  organs ;  fatty  degeneration  of  heart,  liver,  and  kidneys ;  hydrone- 
phrosis on  the  right  side  with  early  atrophic  changes  in  the  right  kidney. 

On  cutting  through  the  abdominal  wall  near  the  line  of  incision,  yellowish- 
white  pus  exudes  from  the  muscles  and  external  to  them.  Over  the  parietal 
peritoneum  in  the  neighborhood  of  the  incision  a  fine  deposit  of  fibrin  is  visible. 
The  cellular  tissues  in  front  of  the  bladder  are  markedly  edematous.  The  serous 
coat  of  the  intestine  is  markedly  congested,  especially  at  points  of  contact.  Fine 
and  coarse  flakes  of  fibrin  are  present  on  both  small  and  large  intestine,  espe- 
cially in  the  lower  abdomen.  The  upper  part  of  the  abdomen  and  peritoneum 
covering  the  stomach,  and  the  liver,  are  entirely  free  from  exudate.  Slight  ex- 
cess of  serous  fluid  in  peritoneal  cavity. 

Bacteriological  examination  :  Cover-slips  from  the  pus  in  the  M'ound  and 
from  the  peritoneal  exudate  sIkjw  cocci,  chiefly  in  pairs.  Cultures  made  from 
the  aljdominal  wound,  the  peritoneum,  the  kidney,  the  lungs,  the  spleen,  and 
from  the  heart's  blood  show  myriads  of  colonies  of  streptococci. 

In  such  a  case  as  this  the  vital  resistance  of  the  patient  was  poor  and  the 
virulence  of  tlie  invading  micro-organisms  marked. 

The  next  grade  of  infection  is  less  rapid  in  the  onset  of  its  symptoms,  and 
the  course  of  the  disease  is  more  prolonged.  Pawlowsky  has  designated  this  as 
the  purulent  hemorrhagic  type. 

The  following  case  is  a  good  example  of  this  form :  E.  E.  II.,  !N^o.  6583, 
myomectomy,  Jan.  23,  1893.  An  abdominal  incision  about  14  centimeters  long 
was  made,  exposing  a  globular  uterus  choking  the  pelvis,  with  a  tumor  8'5  centi- 
meters in  diameter  in  its  anterior  wall,  and  a  similar  nodule  also  8'5  centimeters 
in  diameter  in  the  postei'ior  wall.  Incisions  were  made  into  these  nodules,  and 
they  were  enucleated  from  the  uterine  tissue,  the  cavities  created  were  obliter- 
ated by  buried  and  superficial  catgut  sutures ;  several  other  small  nodules  were 
also  enucleated,  and  the  abdomen  was  then  closed  by  four  series  of  buried  catgut 
sutures.     The  duration  of  the  operation  was  thirty-four  minutes. 

The  next  day  the  patient  complained  of  severe  stabbing-like  pains  over  the 


86 


COMPLICATIONS    ARISING   AFTER   ABDOMINAL   OPERATIONS. 


lower  part  of  the  left  lung  ;  the  pain  was  increased  on  deep  inspiration,  the 
tongue  was  moist,  slightly  coated,  and  the  abdomen  was  not  distended. 

Two  days  after  the  operation  the  pulse  was  rapid,  120  to  the  minute,  but 
fair  in  volume  ;  temperature,  10-J:--4°.  Her  expression,  however,  was  bad,  and 
she  was  nauseated  at  intervals  during  the  entire  day.     The  abdomen  was  now 


DAY     OF 
OPERATION 

1 

2 

3 

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190 
180 
!70 
160 
150 
140 

LU 
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130      S 

120 

110 

100 

90 

80 

HOUR 

8 

12 

6 

12 

6 

12 

6 

12 

6 

12 

6 

12 

6 

109° 
108° 
107° 
106° 
105° 
a     104 

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111 

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102 

101° 

loo" 

99° 
98° 

a 

5  N 

ter 

in. 
deal 

h 

; 

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1 

1 

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J 

;\ 

y> 

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Temperature        — Pulse 


Fig.  329. — Chart  of  a  Case  of  Septic   Peritonitis  following  Myomectomy.     Death  on   the  Fourth 

Day.     E.  il.  IL,  6583. 

tympanitic  and  sensitive.  On  reopening  the  lower  angle  of  the  wound  I  was 
unable  to  find  any  evidence  of  suppuration.  Three  days  after  the  operation  the 
temperature  rose  to  107"8°  and  was  quickly  followed  by  death,  with  the  patient 
conscious  to  the  last. 

Autopsy . — Anatomical  diagnosis  :  Stitch-hole  abscesses  ;  purulent  hem- 
orrhagic peritonitis  following  laparotomy  for  myomectomy ;  myomata  of  uterus ; 
acute  splenic  tumor ;  embolic  lung  abscesses ;  congestion  of  lungs  ;  infection  with 
streptococcus  pyogenes   and   staphylococcus    pyogenes   aureus. 


POST-OPERATIVE    SEPTIC    PERITONITIS.  87 

In  the  midline  is  a  linear  wound  12  centimeters  in  length,  situated  between 
the  umbilicus  and  pubes  ;  the  lower  angle  is  gaping,  but  the  upper  part  of  the 
wound  is  united.  On  incising  the  wound,  a  purulent,  sanguineous  exudate  is 
found  between  the  skin  and  the  deep  muscles,  and  the  muscle  wherever  ex- 
posed is  very  red.  On  cutting  through  the  stitches  which  hold  the  abdominal 
walls  together,  small  accumulations  of  pus  are  found  about  the  sutures,  forming 
foci  which  can  be  readily  distinguished  from  the  general  purulent  infiltration  of 
the  wound.  On  removing  some  of  the  sutures,  they  are  found  covered  with 
pus.     The  deep  layer  of  sutures  is  likewise  covered  with  pus. 

The  parietal  peritoneum  is  injected,  and  on  opening  it  an  accumulation  of 
bloody  pus  is  found  just  beneath  the  incision.  The  omentum  is  adherent  to  the 
intestines  and  to  the  parietal  peritoneum,  rolled  up,  intensely  injected,  and  cov- 
ered with  pus.  The  peritoneum  covering  the  intestines  is  vividly  injected,  and 
the  cavity  contains  about  500  cubic  centimeters  of  blood.  The  greatly  dis- 
tended intestines  are  covered  by  a  layer  of  fibrin  and  pus.  In  the  pelvis,  cover- 
ing the  superior  surface  of  the  uterus  and  filling  up  a  large  part  of  the  cavity,  is 
a  mixture  of  pus,  blood,  and  flakes  of  fibrin.  Along  the  superior  surface  of  the 
uterus  a  row  of  sutures  can  be  seen,  and  on  cutting  into  it  there  is  a  globular 
cavity  about  2'5  centimeters  in  diameter  filled  with  blood.  On  removing  the 
superficial  uterine  sutures,  pus  can  be  squeezed  from  the  cavities  left  by  them. 
Both  the  anterior  and  posterior  euls-de-sac- are  covered  by  a  fibrinous  exudate, 
which  anteriorly  is  thick  and  hemorrhagic  and  can  be  stripped  off  from  the 
peritoneum.  The  cavity  of  the  uterus  is  normal.  The  tubes  and  ovaries  are 
normal. 

Bacteriological  Report . — Cover-slips  from  the  catgut  suture  in  the 
subcutaneous  abdominal  wound  show  numerous  cocci  arranged  singly,  in  pairs  or 
in  bunches,  and  in  chains.  Some  cocci  are  enclosed  in  polynuclear  leucocytes. 
Cover-slips  from  the  uterus,  spleen,  liver,  and  kidneys  are  negative  ;  the  small 
purulent  abscesses  in  the  lung  contain  myriads  of  cocci  arranged  in  bunches  and 
chains.  The  cultures  show  the  presence  of  staphylococcus 
pyogenes  aureus  in  the  abdominal  wound,  in  uterine  mus- 
cle, kidneys,  spleen,  and  liver,  and  also  in  the  small  puru- 
lent areas  in  the  right  lung.  Cultures  from  the  fibrin  in  the  pelvis 
yield  two  organisms — a  coccus  and  a  bacillus.  This  coccus  on  agar  rolls  forms 
pin-point  white  circular  colonies.  Cover-glass  preparations  show  it  to  be 
streptococcus  pyogenes.  On  potatoes,  bouillon,  and  agar-slant  it  gives 
the  typical  growth  of  streptococcus  pyogenes.  The  bacillus  proves 
to  be  bacillus  c  o  1  i  communis;  this  organism  is  also  found  in  the 
kidney. 

If  a  patient  is  more  resistant  to  the  invasion  of  the  infection,  the  character  of 
the  exudate  assumes  a  distinctly  fihrino-purulent  character  ;  if  the  case  is  a  pro- 
longed one,  lasting  for  two  to  three  weeks,  the  exiidate  is  entirely  purulent. 
The  last  form  is  the  least  virulent  of  all,  but  at  the  best  is  always  a  most  serious 
condition.  According  to  Pawlowsky,  the  first  evidence  of  resistance  to  micro- 
-organisms on  the  part  of  the  peritoneum  is  the  throwing  out  of  the  exudate.     If 


88  COMPLICATIONS   ARISING    AFTER    ABDOMINAL    OPERATIONS. 

the  progress  of  the  disease  is  slow  he  states  that  the  Ijiiiph  spaces  become  oc- 
cluded with  the  pyogenic  organisms  and  inflammatory  products,  thus  prevent- 
ing the  invasion  of  other  organs  with  the  infecting  germ. 

Modes  of  Origin  of  Septic  Peritonitis. — These  pyogenic  or- 
ganisms may  And  an  entrance  into  tlie  peritoneum  in  a  variety  of  ways  : 

First,  from  the  liberation  during  operation  of  infected  matter,  as  by  the  ruj)- 
ture  of  a  pelvic  abscess  which  has  been  walled  off  by  adhesions. 

Second,  from  injury  to  the  intestinal  coat,  which  permits  the  direct  escape  of 
pus-producing  germs  from  the  bowel. 

Third,  micro-organisms  may  be  imported  into  the  peritoneum  from  without 
by  the  surgeon  or  his  assistants  on  the  hands,  sponges,  instruments,  ligatures,  or 
accessories.  Furthermore,  several  of  these  factors  may  co-operate  in  the  same 
case  to  produce  peritonitis. 

In  a  simple  operation  unattended  with  traumatism  to  the  pelvic  cellular  tis- 
sue or  viscera  there  is  little  to  favor  the  gi-owth  of  organisms,  whereas  in  more 
extensive  operations,  when  there  is  considerable  oozing,  or  when  hemorrhagic 
or  other  dehris  has  been  left  in  the  peritoneal  cavity,  there  is  much  greater  dan- 
ger, and  this  matter  serves  as  a  rich  pabulum  for  the  growth  of  even  a  few  or- 
ganisms which  may  have  gained  access. 

Symptoms  . — Septic  peritonitis  following  an  operation  does  not  manifest 
itself  until  the  germs  have  had  time  to  multiply  and  excite  some  systemic  reac- 
tion. The  signs  of  this  are  both  local  and  general,  depending  respectively  uiDon 
the  reaction  at  the  point  of  infection  and  the  absorption  of  toxic  by-products. 

The  local  reaction  is  a  conservative  effort  on  the  part  of 
Nature  endeavoring  to  limit  the  infection,  and  consists  in  a  gaseous  distention 
of  the  intestines  which  produces  a  marked  tympany  and  so  increases  the  intra- 
abdominal pressure  and  opposes  a  mechanical  hindrance  to  the  distribution  of 
the  septic  fluid.  This  phenomenon  can  be  readily  demonstrated  clinically  by 
injecting  a  colored  fluid  into  a  lax  peritoneal  cavity  and  also  into  a  tense  one ; 
in  the  former  the  fluid  will  be  found  generally  distributed  throughout  the 
cavity,  while  in  the  latter  it  will  be  localized  in  close  proximity  to  the  point  of 
injection. 

As  a  result  of  the  reaction  there  is  an  exudate  of  plastic  lymph 
thrown  out  at  the  point  of  infection,  which  agglutinates  the  surrounding  vis- 
cera and  so  tends  further  to  impede  or  to  limit  the  extent  of  the  infection.  In 
all  cases  W'here  the  peritonitis  is  not  general  its  limitation  is  due  to  these  ad- 
hesions circumscribmg  and  sealing  it  off  from  the  general  peritoneal  cavity. 
A  pus  pocket  may  be  formed  in  this  way  on  the  floor  of  the  pelvis,  or  laterally 
around  the  stump  of  a  bread  ligament,  or  on  the  site  of  an  amputated  or  enucle- 
ated myoma,  or  posterior  to  the  broad  ligaments. 

In  the  rapidly  fatal  type  of  peritonitis  the  surgeon 
may  hesitate  between  the  diagnosis  of  hemorrhage,  shock, 
and  infection.  In  a  case  of  virulent  septic  peritonitis  following  a  sim- 
ple exploratory  incision  for  carcinoma  of  the  peritoneum  the  patient  died  within 
twenty-four  hours  in  a  state  of  profound  depression  without  one  of  the  local 


POST-OPERATIVE   SEPTIC    PERITONITIS.  89 

symptoms  of  peritonitis.  Within  five  hours  the  toxic  effects  of  the  micro- 
organisms began  to  be  manifest.  The  pulse  at  first  rapid,  rising  from  1(»  to 
20  beats  an  hour,  grew  irregular,  and  finally  disappeared. 

The  thermometer  indicated  only  a  temj^erature  of  101°  F.  (38-3°  C.)  in  the 
mouth,  and  yet  the  patient  complain  ed  of  distressing  internal  heat,  which  was 
explained  by  the  rectal  temperature  of  105°  F.  {■i:(yo°  C).  The  heart  sound 
was  weak  and  irregular,  the  skin  cold  and  clammy,  and  the  fingers  and  hands 
assumed  the  typical  appearance  of  the  washerwoman's  hands. 

These  cases  present  a  picture  of  the  most  profound  depression  of  all  the 
vital  functions.  In  the  less  virulent  cases  the  systemic  effects  of  the  absorption 
of  the  toxic  by-products  is  indicated  usually  by  a  chilly  sensation  or  even  a 
rigor,  and  the  pulse  becomes  rapid,  small,  and  wiry.  The  rise  in  temperature  is 
often  abrupt  immediately  after  the  chill,  reaching  101:°  or  105°  F.  (40°  or  40*5° 
C),  or  it  may  not  rise  above  102°  or  103°  F.  (38-9°  or  39-5°  C). 

After  the  first  rise  the  temperature  remains  above  normal,  but  the  subse- 
quent elevation  is  moderate,  rising  higher  in  the  evening  than  in  the  morning, 
although  the  diurnal  variation  is  not  usually  more  than  one  or  two  degrees. 

There  is  constant  abdominal  pain  with  paroxysms,  recurring  every  few 
minutes  and  causing  the  patient  to  cry  out.  The  appearance  of  the  patient 
is  characteristic ;  her  face  is  pinched  and  drawn,  the  eyes  are  hollow,  and  the 
expression  anxious ;  the  skin  is  often  dusky  and  the  forehead  is  bedewed  with 
sweat.  In  no  surgical  disease  do  we  see  a  more  typical  Ilippocratic  facies 
than  in  septic  peritonitis.  Vomiting  is  one  of  the  earliest  symptoms  and  is  fre- 
quent and  persistent,  the  violent  expulsive  efforts  causing  severe  pain  through- 
out the  lower  abdomen,  and  especially  in  the  line  of  incision.  The  contents  of 
the  stomach  are  first  ejected,  followed  by  yellowish  or  greenish  bile,  and  this  by 
a  blackish  fluid.  Later  the  vomiting  becomes  more  retching  in  character  and 
only  small  quantities  of  fluid  are  expelled.  The  patient  can  no  longer  main- 
tain the  prone  posture  on  account  of  the  increased  pain  caused  by  the  tension 
of  the  abdominal  muscles,  and  either  lies  with  her  shoulders  elevated  and  thighs 
drawn  up  or  turns  on  her  side  with  the  body  curved  forward  and  the  thighs 
flexed  on  the  abdomen.  The  thirst  is  often  consuming  and  insatiable,  and  is 
not  relieved  even  by  the  ingestion  of  large  quantities  of  fluid,  which  the  patient 
constantly  craves,  regardless  of  the  fact  that  drinking  makes  the  vomiting  worse. 

The  respiration  is  costal  in  type  as  the  diaphragmatic  movements  greatly  in- 
crease the  jmin.  In  the  majority  of  cases  the  tympanites  is  extreme,  although 
in  some  of  the  most  virulent  cases  tlie  abdomen  may  be  quite  lax. 

Usually  the  symptoms  of  septic  peritonitis  appear  on  the  second  or  third 
day  after  operation,  and  rim  a  course  of  from  three  days  to  a  week,  or  may 
even  be  prolonged  to  eight  or  ten  days,  depending  upon  the  virulence  of  the 
infection,  the  resisting  and  eliminating  powers  of  the  system,  and  the  limitation 
of  the  inflammatory  process  l)y  local  barriers. 

All  cases  do  not  run  the  typical  course  just  described.  There  may  be  marked 
variations  in  the  most  imjiortant  sym])toms ;  thus  the  ])ulse  at  the  outset  may 
continue  full  and  strong  and  but  slightly  accelerated,  failing  only  after  two  or 


90  COMPLICATIONS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 

three  days.  Yomiting  may  only  occur  at  intervals  of  a  few  hours,  and  the 
stomach  may  even  retain  all  that  is  administered  by  the  mouth.  Just  before 
death,  however,  a  liter  or  more  of  the  fluid  may  be  ejected,  demonstrating  the 
futility  of  giving  medicine  and  nutriment  by  this  avenue.  Such  cases  simulate 
at  their  outset  the  simple,  frank,  non-septic  peritonitis. 

In  other  instances  the  first  symptom  noted  will  be  mild  delirium,  especially 
at  night,  indicated  by  a  slight  incoherence  in  speech,  slowness  of  comprehension, 
or  a  peculiar  somnolence.  The  cases  in  which  the  abdomen  remains  flat  through- 
out the  course  of  the  disease  are  the  worse  forms  of  peritonitis  in  which  there 
is  no  attempt  at  a  local  reaction,  and  the  patients  quickly  succumb. 

Prognosis. — Diffuse  septic  peritonitis  usually  terminates  in  death.  The 
most  virulent  form  will  kill  the  patient  within  twenty-four  or  forty-eight  hours, 
but  death  occurs  usually  within  four  or  five  days.  If  the  pulse  continues  rapid 
and  feeble,  ranging  between  140  and  160,  and  there  is  no  abatement  in  the  fever 
for  two  or  three  days,  the  prognosis  is  bad.  In  such  cases  the  pain  is  usually  se- 
vere, the  vomiting  persistent,  and  the  patient  finally  dies  in  collapse.  In  less  aggra- 
vated cases  the  patient  may  live  for  eight  or  ten  days  and  then  die  of  exhaustion. 

A  falling  temperature  and  steady  general  improvement  in  the  pulse  indicate 
a  favorable  termination.  In  such  cases  there  may  be  complete  resolution,  or  a 
circumscribed  collection  of  pus  may  remain  as  a  sequel  of  the  attack. 

Diagnosis . — In  typical  cases  the  tympanites,  the  constipation,  the  fever, 
the  rapid  and  feeble  pulse,  the  jjeculiar  facial  expression,  and  the  vomiting  are 
so  characteristic  of  the  affection  that  a  diagnosis  can  be  made  without  difficulty. 
A  rapid  pulse,  excessive  pain,  tympanites,  or  persisting  vomiting,  may  mislead 
the  surgeon  temporarily,  but  these  conditions  will  be  differentiated  from  a 
septic  peritonitis  in  the  absence  of  the  other  symptoms. 

Tabulated  Symptoms  of  both  Traumatic  and  Septic 
Peritonitis . — In  view  of  the  necessity  of  recognizing  the  essential  points  in 
the  diagnosis  of  the  two  forms  of  peritonitis,  I  here  tabulate  the  leading  symp- 
toms of  both. 

SIMPLE    TRAUMATIC    PERITONITIS.  SEPTIC    PERITONITIS. 

Symptoms  follow  directly  upon  operation.  Symptoms  often  delayed  two  or  three  days. 

Pain  often  severe.  Pain    intermittent    and   excessive.     Absent    in 

worse  forms. 

Tympany  variable,  generally  not  excessive.  Tympany  excessive,  in  bad  forms  often  absent. 

Tenderness  on  pressure.  Tenderness  on  pressure  excessive. 

Vomiting  occasional,  but  not  as  a  rule  excessive.     Vomiting  frequent,  protracted  and  retching  in 

character,  like  that  of  seasickness. 

Temperature  only  slightly  elevated.  Temperature  usually  high,  remaining  elevated, 

with  slight  or  no  tendency  to  fall. 

Pulse  full  and  quickened,  regular,  not  often  Pulse  rapid,  feeble,  rate  increasing,  running 
above  120.  from  130  to  140  and  above. 

Pacial  expression  good.  Facial  expression  pinched,  anxious. 

Mind  clear.  Mind  becomes  cloudy,  muttering  in  sleep,  ten- 

dency to  delirium. 

Oeneral  appearance  that  of  a  patient  not  dan-  The  general  appearance  that  of  one  extremely 
gerously  ill.  ill. 


POST-OPERATIVE    SEPTIC    PERITONITIS.  91 

Treatment  of  Septic  Peritonitis  —  Prophylaxis. — As  tlie 
most  important  developments  in  surgery  of  recent  years  have  been  directed 
toward  securing  asejDtic  conditions  in  and  about  the  field  of  operation,  an  im- 
perative obligation  rests  upon  the  surgeon  to  observe  the  most  scrupulous  care 
in  keeping  infectious  material  out  of  the  peritoneum.  To  this  end  the  field  of 
operation,  instruments,  ligatures,  sponges,  dressings,  and  the  hands  of  the  sur- 
geon and  assistants  must  be  sterile  and  must  be  maintained  in  this  condition. 
It  is  only  by  obser\aug  these  precautions  rigidly  that  the  surgeon  is  relieved  of 
personal  responsibility.  Under  such  conditions  all  the  simpler  abdominal  opera- 
tions will  run  a  favorable  course. 

When  the  operation  is  directed  against  encapsulated  septic  foci  within  the 
abdomen,  such  as  pyosalpinx  and  ovarian  abscess,  the  purulent  mass  should 
always,  if  possible,  be  removed  without  rupture ;  this  can  only  be  done  safely 
when  the  sac  is  small  and  comparatively  free.  If  the  sac  is  large  or  adherent, 
it  should  first  be  emptied  by  aspiration  and  then  enucleated. 

Sponges  and  gauze  which  have  become  contaminated  must  be  discarded,  and 
fresh  ones  packed  in  around  the  mass  before  finishing  the  enucleation.  After 
the  free  pus  has  been  removed,  the  hole  in  the  sac  must  be  closed  by  a  suture, 
and  the  surgeon  and  assistants  must  wash  their  hands.  During  the  evacuation 
of  the  pus  only  the  surgeon  and  one  assistant  who  handles  the  sponges  should 
come  in  contact  wdth  it,  the  first  and  second  assistants  avoiding  contamination  as 
scrupulously  as  possible.  When  the  coJlapsed  sac  is  loosened  and  lifted  up  I  slip 
a  gauze  bag  over  it  several  folds  thick,  pull  the  draw  string  tight  around  the  neck 
of  the  tumor,  and  hold  it  protected  in  this  way  until  it  is  completely  taken  out. 

If  any  septic  matter  escapes  into  the  pelvis  or  gets  into  the  abdomen,  the 
lower  or  the  entire  abdominal  cavity,  according  to  the  extent  of  the  distribution, 
should  be  washed  out  with  a  normal  salt  solution  at  a  temperature  of  4:33  C 
(110  F.).  At  tlie  completion  of  the  enucleation  the  peritoneal  cavity  should 
again  be  washed  out  with  two  or  three  liters  of  salt  solution. 

Many  cases  are  obviated  by  draining  pelvic  abscesses  into  the  vault  of  the 
vagina  instead  of  attempting  a  trans-peritoneal  enucleation. 

Intestinal  injuries  occurring  during  the  course  of  an  operation  must  be  care- 
fully sutured  at  once,  in  order  to  secure  accurate  union  of  the  serous  and  mus- 
cular coats  of  the  bowel,  and  so  prevent  the  escape  of  septic  matter  from  the 
bowel  into  the  peritoneal  cavity. 

The  careful  checking  of  all  oozing  must  also  be  one  of  the  cardinal  prin- 
ciples in  all  these  cases. 

The  danger  of  fluids  in  dead  spaces  in  the  peritoneal  cavity  has  been  recog- 
nized for  many  years.  Sims  believed  that  it  was  the  serous  discharge  which 
developed  some  toxic  principle  while  stagnating  in  the  peritoneal  cavity  that 
caused  the  frequent  occurrence  of  post-operative  peritonitis,  and  for  this  reason 
he  devised  a  cannula  for  insertion  into  Douglas's  cul-de-sac,  to  drain  the  serum 
and  blood  as  it  w^as  discharged  from  the  injured  tissues. 

By  the  absolute  control  of  all  oozing  we  obviate  the  necessity  for  drainage, 
which  is  itself  a  cause  of  peritonitis. 


92  COMPLICATIOXS    ARISING    AFTER   ABDOMINAL    OPERATIONS.       " 

Handling  the  intestines  and  the  parietal  peritoneum  must  be  avoided  as  much 
as  possible,  and  if  the  intestines  are  exposed  they  should  be  covered  with  gauze 
saturated  with  warm  normal  salt  solution,  which  nmst  be  renewed  as  often  as  it 
gets  cool. 

The  rough  retraction  of  the  walls  of  the  abdominal  incision  with  heavy 
metal  retractors  must  be  avoided.  If  there  is  the  least  question  as  to  the  thor- 
ough disinfection  of  the  surgeon's  or  assistants'  hands,  rubber  gloves  boiled  in 
soda  solution,  as  lirst  used  by  Halsted,  must  be  worn. 

In  all  operations  where  frequent  sponging  is  necessary,  especially  if  reef 
sponges  are  used,  the  assistant  in  charge  of  this  duty  should  wear  gloves,  and  it 
will  be  safer  if  all  but  the  operator  are  similarly  protected. 

Sterilized  white  cotton  gloves  used  in  my  clinic  afford  a  sufficient  protection 
for  the  assistants  who  handle  instruments  and  ligatures,  as  they  prevent  the 
transference  of  any  particles  of  matter  from  the  hands  to  the  patient.  They 
must  be  sterilized  after  every  use,  or  after  any  contamination. 

In  view  of  the  possibility  of  limiting  the  infection  and  arresting  traumatic 
inflammation  in  its  incipien-cy,  the  bowels  should  be  thoroughly  evacuated,  for 
by  this  means  the  pelvic  circulation  is  depleted  and  the  absorption  of  extrava- 
sated  blood  and  serum  from  the  peritoneal  cavity  is  promoted.  The  remedies 
suggested  under  the  treatment  of  traumatic  peritonitis  may  be  employed  at  the 
onset  of  the  symptoms  of  septic  peritonitis,  as  the  indications  to  be  met  at  this 
time  are  the  same  in  both  conditions.  The  severity  of  the  vomiting  usually  pre- 
cludes the  administration  of  purgatives  by  the  mouth,  and  often  the  enemata  are 
repeatedly  expelled  only  slightly  tinged  with  fecal  matter,  and  the  bowels  re- 
main unmoved  until  death. 

When  the  distention  of  the  abdomen  is  not  extreme  the  constant  application 
of  ice  bags  over  the  lower  abdomen  during  the  early  stage  is  of  value  in  limiting 
the  inflammatory  process. 

Strychnin  hypodermically  may  be  given,  in  the  dose  of  one  sixtieth  to  one 
fortieth  of  a  grain  every  hour,  to  sustain  the  heart  and  the  nervous  system. 
Morphin  may  be  used  for  the  relief  of  extreme  suffering  or  when  a  fatal  issue  is 
unavoidable  Whenever  the  temperature  rises  above  38°  C.  (101°  to  103°  F.) 
sponging  the  body  and  limbs  with  cold  or  iced  water  will  be  of  material  assist- 
ance in  limiting  or  reducing  the  temperature.  The  administration  of  food  by 
the  mouth  is  rarely  of  use,  as  it  is  usually  vomited,  or  if  retained  it  is  not  ab- 
sorbed. If,  however,  the  intervals  between  the  attacks  of  vomiting  are  not 
too  short,  a  half  drachm  of  liquid  food,  such  as  milk  and  limewater,  may  be 
given  every  fifteen  minutes  with  the  hope  that  some  of  it  will  be  altsorbed.  The 
strength  of  the  patient  must  be  maintained  by  nutritive  and  stimulating  enemata 
every  six  or  eight  hours,  according  to  the  tolerance  of  the  rectum. 

Operative  Treatment . — I  heartily  condemn  the  general  rule  of  opening 
the  abdomen  as  soon  as  a  septic  peritonitis  is  suspected.  Often  there  is  a  mis- 
take in  the  diagnosis,  and  with  a  little  patience  untoward  symptoms  will  subside 
and  the  patient  will  recover  without  operation,  and  in  other  cases  the  operation  is 
hopeless  from  the  outset,  and  the  patient  succumbs  all  the  quicker  because  of  it. 


POST-OPERATIVE    SEPTIC    PERITONITIS.  93 

I  know  of  no  class  of  cases  in  wliicb  it  is  more  difficult  to  decide  when  to 
operate  and  when  not  to  operate,  and,  in  spite  of  a  wide  experience  and  a  careful 
study  of  all  the  clinical  signs  in  each  case,  I  still  occasionally  make  mistakes  and 
open  the  abdomen  to  find  no  peritonitis  where  it  was  believed  to  be  present,  or, 
thinking  the  symptoms  will  subside,  I  wait  until  it  is  too  late  and  the  disease  is 
beyond  control.  This  liability  to  error  is  due  to  the  fact  that  in  its  early  stages 
a  septic  peritonitis  may  simulate  a  variety  of  simple  complications,  making  a 
differential  diagnosis  absolutely  impossible. 

If  any  definite  nile  could  be  laid  down  by  which  we  could  recognize  a  septic 
infection  in  its  iucipiency,  the  rule  would  be  to  reopen  the  abdomen  at  once  and 
clean  out  the  peritoneum  and  close  uj)  the  abdomen,  or  in  most  cases  clean  out 
and  drain,  with  the  exception  of  a  small  group  in  which  absolutely  all  that  can 
be  accomphshed  has  been  done  at  the  first  operation.  Such  exceptions,  for 
example,  are  incomplete  operations  and  operations  in  which  the  patient  is  so  ex- 
hausted that  she  can  not  possibly  stand  any  further  strain. 

A  septic  peritonitis  in  its  earliest  stages  must  be  distinguished  from  excessive 
tymjDany,  excessive  nausea,  excessive  pain,  unusual  torpor  of  the  bowels,  unduly 
elevated  temperature,  and  rapid  pulse  on  the  one  hand,  and  from  hemorrhage 
and  auto -intoxication  on  the  other. 

That  surgeon  will  best  differentiate  his  cases  who  unremittingly  watches 
every  symptom  of  the  early  convalescence  and  proceeds  at  once  to  meet  any 
complication  that  may  arise. 

Two  points  must  be  well  weighed  in  the  decision  in  every  doubtful  case — in 
the  first  place  the  character  of  the  operation,  and  in  the  second  place  the  condi- 
tions surrounding  the  operation — that  is  to  say,  the  character  of  the  technique 
of  the  operation. 

If  at  the  time  of  operation  the  condition  of  the  patient  was  bad  and  septic 
foci  were  opened  up  and  the  peritoneum  widely  contaminated,  or  if  the  in- 
testines required  extensive  suturing,  then  the  decision  that  a  post-operative 
septic  peritonitis  is  under  way  will  be  more  readily  adopted  than  in  a  case 
where  these  complications  were  absent,  for  the  percentage  of  septic  cases  is 
vastly  greater  after  complicated  than  after  simpler  operations. 

Again,  if  the  operation  has  been  conducted  under  circumstances  which  pre- 
vented the  carrying  out  of  a  satisfactory  technique,  as,  for  example,  in  an  emer- 
gency case  at  the  home  of  the  patient,  or,  when  the  assistance  has  been  poor, 
a  septic  peritonitis  will  be  suspected,  when  in  another  case  with  similar  symp- 
toms the  absolute  assurance  that  the  technique  has  been  perfect  in  all  respects 
will  give  the  operator  courage  to  persist  in  a  purely  palliative  line  of  treat- 
ment. 

A  sudden  severe  i  n  t  r  a  j)  e  r  i  t  o  n  e  a  1  he  m  o  r  r  h  a  g  e  is  marked  by 
symptoms  of  rapid  collapse,  anemia,  small  vanishing  pulse,  and  precordial  dis- 
tress with  air-hunger.  The  sudden  anemia  and  the  remarkable  rapid  change  in 
the  pulse  serve  to  distinguish  this  condition  from  peritonitis ;  in  either  case  the 
treatment,  so  far  as  it  relates  to  opening  the  abdomen  promptly  and  controlling 
the  disease,  is  the  same. 


94:  COMPLICATIONS    ARISING   AFTER    ABDOMINAL   OPERATIONS. 

In  the  event  of  a  slow  hemorrhage  the  signs  become  most  distinct  with  the 
onset  of  a  peritonitis,  when  the  indication  is  also  to  open  the  abdomen  and  clean 
out  the  peritoneum. 

Auto-intoxication  by  absorption  of  toxic  elements  from  the  intestinal  tract 
sometimes  closely  mimics  the  severe  forms  of  general  septic  peritonitis.  The 
patient  lies  listless  with  a  dark  skin  and  sunken  eyes,  vomiting  occasionally,  with 
a  quickened  pulse,  and  some  elevation  of  temperature  and  tympany  which  may 
be  excessive. 

The  chief  differences  lie  in  the  fact  that  the  expression  lacks  the  collapsed 
pinched  look  of  peritonitis,  the  vomiting  is  not  usually  of  the  persistent  and 
bilious  character,  and  there  is  no  progressive  change  from  bad  to  worse.  Any 
gases  which  pass  and  alvine  evacuations  are  intensely  fetid. 

Other  complications,  such  as  tympany,  nausea,  pain,  and  sluggish  bowels,  are 
distinguished  by  the  absence  of  the  train  of  symptoms  of  a  peritonitis. 

The  onset  of  a  septic  peritonitis  is  usually  noticeable  within  the  first  thirty- 
six  hours ;  the  pulse  rises  20  or  80  beats,  the  temperature  goes  up  two  or  three 
degrees,  tympany  increases  until  the  abdomen  is  distended  as  tight  as  a  drum, 
and  breathing  is  embarrassed;  the  abdominal  pains  recur  at  short  intervals 
and  vomiting  increases  in  frequency,  the  stomach  pouring  out  quantities  of 
black  bile.  The  bowels  obstinately  refuse  to  respond  to  every  eifort  to  secure 
a  movement.  There  is  soon  a  notable  diminution  in  the  quantity  of  urine 
passed,  so  marked  in  some  cases  as  to  induce  the  operator  to  think  he  may  have 
tied  a  ureter.  The  expression  of  the  patient  shows  that  she  is  desperately  ill, 
and  in  the  later  stages  the  appearance  is  that  of  collapse.  In  the  worst  cases 
the  septic  intoxication  is  so  virulent  that  none  of  the  reactionary  symptoms  have 
time  to  develop,  and  she  dies  without  much  vomiting,  or  any  tympany  at  all,  or 
any  elevation  of  temperature.  The  pulse,  quickened  at  first,  breaks  down  sud- 
denly and  runs  up  to  150,  160,  and  on  up  beyond  counting. 

Whenever  the  patient  is  evidently  going  from  bad  to 
worse,  and  the  symptoms  point  distinctly  toward  peri- 
tonitis,   it   will    be    best    to    operate    at    once. 

In  a  doubtful  case  it  is  important  to  begin  at  once  in  the  effort  to  evacuate 
the  bowels  by  giving  calomel  in  a  dose  of  3  or  4  grains  followed  by  an  enema 
of  half  a  liter  of  warm  water  and  soapsuds  containing  about  three  ounces  of 
sweet  oil  and  half  a  teaspoonful  of  turpentine. 

Castor  oil  is  sometimes  a  good  addition  to  the  enema,  or  a  saturated  solution 
of  sulphate  of  magnesia  may  be  given  in  a  three-ounce  mixture. 

When  the  pain  is  excessive  a  small  dose  of  morphin  or  codein  in  half -grain 
doses  hypodermically  must  be  used. 

Preceding  an  operation  for  septic  peritonitis  the  abdo- 
men must  be  examined  with  the  utmost  care  to  discover 
any  evidences  of  localized  inflammation  or  suppuration. 
The  vagina  also  must  be  examined  for  evidences  of  fix- 
ation of  the  cervix  on  one  or  both  sides,  or  of  any  fluid 
accumulation   just   above   the  vaginal  vault. 


POST-OPERATIVE    SEPTIC    PERITONITIS.  95 

The  discovery  of  a  point  of  localization  of  the  infection  gives  the  operation 
a  definite  objective  point  and  may  limit  its  scope. 

The  sthenic  type  of  case,  where  the  infection  is  still  localized,  offers  the  best 
hope  of  a  recovery  after  a  secondary  operation ;  in  such  cases  there  is  evidence 
of  a  strong  resistance  to  the  infection,  revealed  principally  in  the  pulse,  which 
remains  of  good  volume  and  advances  in  its  rate  but  slowly,  and  the  appearance 
of  collapse  is  wanting.  In  suitable  cases  an  examination  of  the  abdomen  will 
often  reveal  areas  of  hardness  and  fluctuation  in  the  pelvis  surrounded  by  tym- 
panitic bowels.  A  vaginal  and  rectal  examination  shows  the  presence  of  hard 
masses  on  one  or  both  sides,  and  sometimes  of  fluctuation. 

There  are,  in  general,  two  methods  of  procedure  in  the  operative  treatment 
of  septic  peritonitis — first,  the  evacuation  of  pockets  of  pus  or  fluid  by  a  vaginal 
incision  ;  second,  reopening  the  incision  to  clean  out  septic  fluids. 

The  first  method  is  available  in  a  small  percentage  of  cases  only,  where  an 
infection  is  localized  on  the  pelvic  fioor.  In  such  cases  the  incision  may  be  made, 
when  distinct  fluctuation  is  felt  through  the  vaginal  vault.  Preliminary  to  mak- 
ing the  opening  the  vagina  must  be  thoroughly  cleansed ;  the  patient  is  then 
brought  to  the  edge  of  the  table  and  a  free  incision  is  made  posterior  to  the 
cervix,  opening  up  the  abscess,  which  is  washed  out  and  drained  for  a  few  days 
with  iodoform  gauze.  A  finger  in  the  rectum  serves  to  protect  the  bowel  from 
any  injury  during  the  operation. 

Where  the  infection  is  not  clearly  localized  the  better  plan  of  procedure  is 
to  reopen  the  incision  and  so  expose  the  wounded  area  in  the  pelvis,  which  is 
in  almost  all  cases  the  focus  of  the  infection. 

The  choice  of  an  anesthetic,  indeed  the  propriety  of  using  any  form  of 
anesthesia,  is  a  question  of  vital  import.  When  the  pulse  is  rapid  and  feel)le — 
running  above  135— and  the  patient  is  greatly  depressed,  no  anesthetic  should 
be  given,  or,  at  the  utmost,  but  a  few  whiffs  of  chloroform  when  she  begins  to 
struggle  after  the  incision  is  reopened.  The  production  of  complete  anesthesia 
under  these  circumstances  is  often  followed  by  heart  failure,  the  pulse  running 
higher  and  higher  until  it  disappears.  If  the  patient's  condition  permits  the  use 
of  an  anesthetic,  chloroform  is  to  be  preferred  to  ether  on  account  of  its  speedier 
action.  A  further  objection  to  the  use  of  ether  is  that  cardiac  failure,  in  a  heart 
already  depressed  by  septic  poison,  is  more  likely  to  follow  the  struggling  and 
vomiting  attending  its  administration  than  it  is  to  occur  from  the  depressing 
effect  of  chloroform. 

At  first  only  the  subcutaneous  and  one  buried  silver-wire  suture  are  removed 
from  the  lower  angle  of  the  wound— enough  to  permit  the  introduction  of  the 
index  and  middle  fingers.  The  lips  of  the  wound  are  separated  by  the  finger, 
or,  if  too  adherent,  by  introducing  scissors,  spreading  the  blades.  Especial  care 
must  be  taken  in  reopening  the  incision  to  keep  in  the  median  line,  and  not  to 
dissect  up  the  tissues  on  either  side. 

At  the  bottom  of  the  wound  appears  the  puckered  peritoneum,  Avith  its  con- 
tinuous suture,  which  should  be  Ufted  uj)  with  the  dressing  forceps  and  cut. 

Separating  the  peritoneum,  the  index  finger  is  inserted,  and  if  it  encounters 


96  COMPLICATIONS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 

adherent  intestines,  it  is  carried  down  under  the  abdominal  wall  and  over  the 
top  of  the  bladder  to  the  uterus  and  broad  ligaments. 

Pockets  of  pus  are  readily  recognized  by  the  finger  tips,  and  the  nature  of 
the  discharge  can  be  further  verified  by  noting  the  character  of  the  fluid  with- 
drawn on  the  fingers.  If  there  is  a  large  quantity  of  fluid  confined  under  ten- 
sion, it  will  gush  forth  from  the  incision  as  soon  as  it  is  opened.  A  small  sponge 
on  a  holder  may  be  used  to  remove  this,  observing  the  utmost  care  to  avoid 
separating  the  coils  of  intestines  adjacent  to  the  purulent  focus. 

A  gentle  bimanual  examination  should  be  made  before  closing  the  incision, 
with  one  finger  in  the  peritoneal  cavity  palpating  through  the  adherent  intes- 
tines, and  the  other,  protected  by  sterilized  rubber  gloves,  introduced  into  the 
vagina. 

Other  deposits  are  easily  felt  at  the  sides  and  broken  open  so  as  to  discharge 
into  the  main  cavity  first  opened. 

Irrigation  should  only  be  employed  when  the  infection  is  so  widespread  that 
it  can  not  be  removed  in  any  other  way. 

Drainage  is  the  mainstay  in  the  treatment  after  operation  ;  sufiicient  gauze 
sliould  be  loosely  packed  in  to  fill  tlie  cavity,  leaving  one  end  projecting  from 
the  lower  angle  of  the  wound. 

If  a  generalized  peritonitis  is  found  the  treatment  must  be  even  more  radical. 
A  sufliciently  long  incision  to  admit  of  easy  access  to  all  parts  of  the  peri- 
toneum is  made.  Quickly  withdraw  the  coils  of  small  intestines  from  the 
peiitoneal  cavity,  beginning  with  the  worst  coils.  Remove  all  or  as  much  as  is 
necessary  of  the  small  intestine,  and  place  to  one  side,  covered  with  gauze  or 
towels,  thus  practically  disemboweling  the  patient  for  the  time  being.  Then 
thoroughly  and  systematically  wipe  out  the  peritoneal  cavity  with  large  pledgets 
of  gauze  wrung  out  of  hot  salt  solution,  paying  especial  attention  to  the  pelvic 
portion.  Next,  the  small  intestine  should  be  systematically  gone  over  loop  by 
loop,  while  still  outside  the  abdomen,  and  rendered  macroscopically  clean  by 
wiping  with  gauze  compresses  wrung  out  of  hot  salt  solution.  It  is  necessary 
to  use  a  considerable  amount  of  force  at  times,  in  order  to  remove  adherent 
flakes  of  partly  organized  lymph.  It  should  be  done  thoroughly  and  conscien- 
tiously, however,  as  upon  this  depends,  we  believe,  in  great  measure,  the  success 
of  the  operation.  It  facilitates  the  cleansing  process,  as  well  as  lessens  the  shock 
of  the  operation,  if  the  wiping  of  the  intestinal  coils  is  carried  on  under  a  con- 
tinuous irrigation  of  warm  salt  solution. 

After  being  cleansed  macroscopically  of  all  foreign  material,  pus,  blood, 
lymph,  etc.,  the  intestine  should  be  replaced  in  the  abdomen  ;  if  there  has  been 
any  intestinal  suture  the  worst  or  sutured  coil  is  returned  last,  and  left  most 
superficial,  in  order  tliat  it  may  be  the  better  drained  by  being  packed  about 
with  gauze  if  necessary.  The  abdominal  wound  should  then  be  sutured  in  the 
usual  manner,  leaving  just  room  enough  for  the  gauze  drain. 

Six  cases  of  general  septic  peritonitis  have  been  operated  upon  up  to  the 
present  time  by  Dr.  J.  M.  T.  Finney,  the  originator  of  this  method,  and  five  of 
them  recovered. 


FERMENTATION    AND    SEPTIC    FEVERS.  97 

Fermentation  and  Septic  Fevers. — "  It  is  desirable  to  distinguish  from  septic 
peritonitis  certain  jjost-operative  pathological  and  clinical  states  which  arise  in- 
dependently of  the  invasion,  either  of  the  peritoneum  or  the  body  at  large,  by 
pathogenic  micro-organisms ;  and  it  is  further  necessary  to  consider  some  of  the 
more  remote  consequences  of  the  development  in  the  peritoneal  cavity  of  pyo- 
genic bacteria."  The  terms  septic  intoxication,  septicemia,  and  pyemia  are  by 
some  employed  more  or  less  interchangeably  to  designate  certain  symptoms 
arising  from  a  bacterial  infection  of  the  body  at  large. 

"  Although  septic  intoxication  can  be  separated  more  or  less  readily  from 
septicemia  and  pyemia,  the  distinction  between  the  two  latter  conditions,  while 
important  from  a  surgical  standpoint  and  convenient  from  pathological  grounds, 
is  much  more  artificial." 

In  septicemia  small  foci  of  degenerated  cells  and  necroses  of  cells  are  often 
found  within  the  viscera,  and  it  is  therefore  not,  as  it  is  frequently  described,  a 
disease  "without  demonstrable  lesions"  in  contradistinction  to  pyemia,  which 
invariably  shows  foci  of  suppuration  and  necroses. 

Septicemia  and  pyemia  may  be  but  stages  of  one  process,  for  in  some  cases 
pyogenic  bacteria  may  gain  entrance  to  the  blood  and  circulate  throughout  the 
tissues,  producing  the  characteristic  symptoms  of  septicemia.  The  process  may 
be  held  in  check  at  this  point,  or  it  may  go  on  to  the  formation  of  focal  necroses 
or  suppuration  in  the  viscera  at  some  point  remote  from  the  original  portal  of 
entrance,  with  the  attendant  symptoms  of  pyemia.  Septicemia  and  pyemia  are 
therefore  but  the  generalization  through  the  vascular  system  of  the  infection 
which  has  first  been  local ;  for  example,  septicemia  often  supervenes  upon  a  sep- 
tic peritonitis  in  its  later  stages,  and  septicemia  or  pyemia  may  be  the  result  of 
an  infected  peritoneal  wound. 

The  organisms  which  most  frequently  produce  septicemia  and  pyemia  ai-e  the 
streptococcus,  the  staphylococcus  aureus,  alb  us,  and  c  i  t  - 
reus,  the  micrococcus  lanceolatus,  and  more  rarely  the  colon 
bacillus,  the  gonococcus,  the  c  a  p  s  u  1  a  t  e  d  bacillus  of  Fried- 
lander,  and  the  typhoid  bacillus. 

In  surgical  cases  the  last  two  organisms  are  rarely  met  with.  Any  of  these 
organisms  may  produce  either  septicemia  or  pyemia,  but  the  streptococcus  is 
more  likely  to  produce  septicemia  when  it  is  the  infecting  organism. 

That  the  staphylococci  are  often  present  in  local  lesions  without  pro- 
ducing septicemia  or  pyemia  is  shown  by  the  fact  that  they  are  frequently  found 
in  localized  infections,  such  as  stitch-hole  and  intramural  abscesses,  and  rarely 
produce  more  than  a  local  reaction,  while  patients  infected  with  streptococci 
in  the  same  situations  rarely  escape  so  easily. 

The  grave  puerperal  infections  are  most  frequently  produced  by  the  stre})- 
t  o  c  o  c  c  u  s ,  and  the  slow  convalescence  in  these  cases  with  all  the  aceompanyiug 
symptoms  of  general  invasion  or  infection  are  well  known. 

There  seems  to  be  a  larger  variety  of  organisms  which  are  capable  of  pro- 
ducing septicemia  than  pyemia,  for  instance  the    p  r  o  t  e  u  s   vulgaris    may 
produce  septicemia,  but  thus  far  it  has  not  been  found  in  a  true  pyemia. 
47 


98  COMPLICATIOXS    ARISI^TG    AFTER    ABDOMINAL    OPERATIONS. 

Some  of  the  specific  organisms  wliicli  iisnallj  are  the  etiological  factors  in 
inflammation  peculiar  to  them  may  under  certain  conditions  give  rise  to  septice- 
mia. Such  examples  are  furnished  by  the  micrococcus  1  a  n  c  e  o  1  a  t  u  s 
and  the   g  o  n  o  c  o  c  c  u  s . 

Tliat  we  can  not  take  a  particular  pathogenic  organism  and  say  that  it  will 
invariably  produce  pyemia  or  septicemia  is  illustrated  by  the  fact  that  the 
p  n  e  u  m  o  c  o  c  c  u  s  which  produces  in  man  localized  inflammations,  such  as 
croupous  pneumonia,  etc.,  in  animals  tends  to  end  in  septicemia. 

Sapremia,  according  to  the  older  conception  of  the  term,  implied  that  at 
some  point  in  the  body  there  was  a  focus  of  putrescent  matter  containing  prod- 
ucts of  decomposition,  and  the  absorption  from  this  area  gave  rise  to  the  toxic 
symptoms.  In  these  cases  the  symptoms  were  supposed  to  be  due  to  the  absorp- 
tion of  toxines  or  ptomaines  elaborated  by  the  putrefactive  bacteria,  and  not  to 
the  entrance  of  organisms  themselves  into  the  blood. 

More  recent  investigators  have  shown  that  this  theory  is  not  tenable  because 
all  pathogenic  organisms  are  capable  of  producing  toxic  substances  of  one  kind 
or  another  which  are  injurious  to  life.  The  by-products  of  the  putrefactive  bac- 
teria closely  resemble  in  poisonous  qualities  those  of  the  pathogenic  bacteria, 
but  in  locally  infected  wounds  the  former  are  rarely  met  with  while  the  latter 
are  uniformly  present.  This  forces  us  to  ascribe  the  symptoms,  frequently 
attributed  to  putrefactive  intoxication,  to  the  absorption  of  toxines  elaborated  by 
the  more  common  pyogenic  organisms. 

For  this  reason  the  terra  "septic  intoxication"  is  a  better  one  under 
which  to  classify  these  symptoms,  because  it  is  sufliciently  broad  to  include  all 
conditions  arising  from  the  absorption  of  toxines  produced  by  any  forms  of  bac- 
teria. 

In  surgical  cases  the  chief  agents  of  septic  intoxication  are  the  pyo- 
genic cocci,  to  which  may  be  added  the  bacillus  pyocyaneus  and  p r o - 
t e u s ,  perhaps  the  colon  bacillus,  and  among  the  anaerobic  forms,  which 
more  closely  resemble  the  putrefactive  germs,  the  bacillus  aero  genes 
capsulatus,  the  importance  of  which  has  not  yet  been  sufficiently  appreciated. 

The  study  of  septic  intoxication  in  human  pathology  is  yet  in  its  infancy, 
and  sufficient  discrimination  has  not  been  made  by  surgeons  between  the  so- 
called  sapremia  and  a  form  of  intoxication  which  may  arise  from  antiseptically 
treated  wounds. 

Under  the  name  "fermentation  fever,"  Bergmann,  Billroth,  and 
Volkmann  liave  described  certain  symptoms  due  to  the  resorption  of  fermenta- 
tion products  or  of  aseptic  tissue  necrosis.  Volkmann  ascribes  the  rise  of  tem- 
perature after  operations  in  which  the  wound  remains  aseptic  throughout  and 
after  operation  to  the  aljsorption  of  dead  tissue.  Bergmann  invented  the  term 
fermentation  fever  for  the  mild  febrile  disturbances  occurring  after  operations, 
believing  that  they  were  due  to  the  absorption  of  fibrin-ferment.  Edell)erg  and 
Angerer  confirmed  this  theory  l)y  injecting  blood  or  its  products  containing 
fibrin-ferment  into  animals,  and  found  that  it  was  invariably  followed  by  a  rise 
of  temperature. 


SEPTIC    IXTOXICATIOX.  99 

"When  viewed  from  this  standpoint  the  common  rise  of  temperatm'e  follow- 
ing all  operations  of  any  magnitude  can  be  much  more  easily  accounted  for  than 
on  the  ground  of  septic  infection,  for  it  is  not  probable  that  under  the  painstak- 
ing technique  of  modern  surgery  all  wounds  should  be  infected  sufficiently  to 
cause  this  increase  in  temperature,  while  few  ojjerations  are  so  slight  as  not  to 
cause  more  or  less  cell  death. 

The  com230site  temperature  and  pulse  charts  which  I  have  constructed  of 
normal  convalescence  after  abdominal  operations  show  this  characteristic  rise  for 
the  first  three  days. 

From  a  clinical  standpoint  I  will  classify  the  febrile  disturbances  due  to  fer- 
mentation and  septic  products  under  the  following  headings  :  1.  Fermentation 
fever.     2.  Septic  intoxication.     3.   Septicemia.     4.  Pyemia. 

Fermentation  Fever. — The  rise  in  temperature  produced  by  the  absorption 
of  fibrin-ferment  and  the  products  of  aseptic  tissue  necrosis  is  usually  shght 
and  of  but  short  duration.  It  is  oftenest  noted  by  the  evening  of  the  day  of 
operation,  and  may  continue  from  twenty -four  to  seventy-six  hours.  Obri- 
ously  the  febrile  disturbances  following  a  simple  abdominal  operation  would  be 
much  less  than  in  those  cases  where  extensive  traumatisms  occur. 

This  slight  rise  of  temperature  (see  composite  charts,  Chapter  XXI)  mav  be 
considered  normal  and  need  give  rise  to  no  anxiety. 

Septic  Intoxication. — This  condition,  like  fermentation  fever,  may  arise 
shortly  after  operation  or  it  may  occur  later  when  toxic  products  are  pro- 
duced in  the  course  of  a  septic  infection.  In  abdominal  operations,  where  pus 
escapes  from  abscesses  and  gains  entrance  into  the  blood  either  through  the 
wounded  tissues  or  through  absorption  from  the  peritoneum,  the  accumulated 
toxic  products  which  it  contains  may  give  rise  to  a  marked  febrile  reaction.  In 
one  case  in  which  I  opened  a  pelvic  abscess  which  contained  no  living  organism, 
the  temperature  rose  abruptly  to  105-5°  F.  (40-8°  C.)  in  a  few  hours,  remained 
at  this  point  for  about  two  hours,  and  then  abruptly  dropped  to  the  normal. 

Associated  with  this  febrile  reaction  are  the  usual  symptoms  of  all  fevers — 
dry  tongue,  thirst,  scanty  high-colored  urine,  flushed  face,  headache,  and  rest- 
lessness. If  the  symptoms  are  due  to  the  temporary  absorption  of  toxic  prod- 
ucts they  disappear  with  the  subsidence  of  the  fever. 

Until  a  marked  amelioration  of  symptoms  occurs,  the  surgeon  will  neces- 
sarily feel  considerable  anxiety,  as  these  same  phenomena  occur  in  acute  septice- 
mia. When  the  symptoms  of  septic  intoxication  arise  three  or  four  days  after 
operation,  the  prognosis  is  more  grave,  because  it  usually  indicates  an  active  in- 
fectious process  which  has  been  generated  in  some  part  of  the  wound. 

The  symptoms  in  these  cases  are  more  gradual  in  their  onset,  as  the  accumu- 
lated toxines  are  not  thrown  at  once  into  the  system,  as  occurs  when  an  abscess 
is  ruptured,  but  by  a  more  gradual  process  associated  with  the  multiplication  of 
the  bacteria.  When  the  septic  intoxication  is  severe  the  systemic  disturbances 
are  usually  initiated  by  a  chill.  The  temperature  rises  more  gradually,  and 
may  not  reach  its  acme  until  three  or  four  tlays.  The  patient  loses  her  ap]>e- 
tite,  the  tongue  becomes  furred   and  dry,  the  skin  is  hut  and  dry,  and  the  tern- 


100  COMPLICATIONS   ARISING    AFTER    ABDOMINAL   OPERATIONS. 

perature  may  reach  as  high  as  105°  F.  (l:0-5°  C),  with  shght  varying  remissions. 
The  urine  becomes  scanty,  high-colored,  and  ranges  in  specific  gravity  from 
1025  to  1030.  Kestlessness,  insomnia,  and  occasionally  delirium,  may  accom- 
pany the  higher  rises  in  temperature.  In  fatal  cases  the  patient  often  sinks 
into  a  lethargic  condition,  which  shades  off  into  coma,  while  in  others  the  symp- 
toms of  profound  shock  predominate.  The  body  is  covered  with  a  profuse 
perspiration,  the  extremities  are  cold,  the  pulse  is  feeble,  fluttering,  or  inter- 
mittent. 

The  prognosis  dejjends  entirely  upon  the  local  septic  process.  If  the  system 
overcomes  the  infection,  or  its  source  is  ehminated  by  surgical  interference,  the 
symptoms  quickly  disappear,  otherwise  a  rapidly  fatal  termination  may  occur 
wnthin  a  few  hours. 

The  differential  diagnosis  between  septic  intoxication  and  septicemia  can 
often  be  made  by  a  bacteriological  examination  of  the  blood.  Blood  cultures 
and  cover-slip  prejDarations  from  the  blood  should  be  made  ;  the  presence  of 
bacteria  indicates  septicemia. 

The  treatment  in  these  cases  is  largely  expectant ;  if  the  patient  can  retain 
fluids,  pure  water  should  be  given  in  abundance  ;  the  use  of  the  saline  enemata, 
which  should  be  given  as  a  routine  procedure  after  all  abdominal  operations,  is 
of  great  service  in  diluting  the  poison  and  in  assisting  the  kidneys  to  eliminate 
it  rapidly.  All  remedies  in  these  cases  should  be  directed  toward  aiding  the 
system  to  eliminate  the  poison. 

Unless  there  is  an  active  intoxication  produced  by  poisons  which  are  being 
constantly  elaborated  at  some  point  and  thrown  into  the  system,  the  symptoms 
will  quickly  subside. 

In  all  cases  where  toxic  symptoms  arise  a  few  days  after  the  operation,  the 
dressings  should  be  removed  and  the  abdominal  wound  carefully  inspected ;  if 
it  appears  healthy,  a  vaginal  examination  should  be  made  to  ascertain  whether 
there  is  a  local  point  of  suppuration  in  the  pelvis.  In  the  early  stages  of  the 
infection  the  local  infectious  process  may  be  inferred  from  an  increased  tender- 
ness or  acute  pain  produced  by  the  pelvic  examination. 

"Where  a  gauze  drain  has  been  inserted,  either  through  the  abdominal  in- 
cision or  through  the  vagina,  the  toxic  symptoms  may  arise  from  the  backing  up 
of  infected  fluids,  the  drain  should  therefore  invariably  be  withdrawn  sufficiently 
to  ascertain  whether  there  is  any  retained  fluid  behind  it. 

If  nothing  distinctive  of  sepsis  is  discovered  the  patient  should  be  watched 
closely  for  the  succeeding  days  when  some  point  hitherto  concealed  may  become 
sufficiently  evident  to  localize  it.  If  suppuration  has  occurred  in  the  abdominal 
wall,  it  should  be  freely  opened  and  repeatedly  and  thoroughly  cleansed  with 
peroxide  of  hydrogen.  When  suppuration  is  detected  about  the  stump  of  an 
amputated  uterus,  or  at  the  site  of  a  pelvic  operation,  it  may  be  reached  and 
drained  either  through  wide  dilatation  of  the  cervix  or  through  a  vaginal  open- 
ing made  in  the  manner  described  in  the  treatment  of  pelvic  abscesses. 

After  the  abscess  has  been  opened  care  should  be  observed  to  keep  the 
passage  patulous  until  the  cavity  has  filled  with  healthy  granulation  tissue.     To 


SEPTICEMIA.  101 

this  end  a  douch  should  be  given  daily,  the  curved  glass  nozzle  inserted  well 
into  the  abscess  cavity.  This  duty  should  be  attended  to  by  the  surgeon,  and 
should  not  be  relegated  to  a  nurse. 

If  the  pulse  shows  signs  of  failure,  infusions  of  normal  salt  solution  should 
be  given  into  the  cellular  tissue  beneath  the  breasts,  employing  at  least  500  to 
1,000  cubic  centimeters  every  twenty -four  hours. 

Sulphate  of  strychnin  in  ^L-  to  ^  grain,  depending  upon  the  urgency  for 
stimulation,  should  be  given  every  two  or  three  hours.  Liquid  diet  should  be 
frequently  administered.  The  bowels  must  not  be  permitted  to  become  con- 
stipated. 

Septicemia.— The  same  symptoms  noted  in  septic  intoxication  are  present  in 
true  septicemia,  but  in  the  latter  condition  they  are  more  marked  and  may  tend 
much  more  rapidly  to  a  fatal  termination. 

Septicemia  may  arise  within  a  few  hours  after  an  operation,  from  a  severe 
form  of  mycotic  peritonitis  or  virulent  infection  of  the  external  wound,  or  it 
may  come  on  days  after  from  some  localized  focus  of  infection,  such  as  an 
intramural  abscess  or  a  suppuration  in  the  peritoneal  cavity. 

In  an  uncomplicated  case  of  hystero-myomectomy,  where  I  had  every  rea- 
son to  believe  that  the  operation  had  been  properly  conducted,  the  patient  died 
within  twenty-four  hours  of  a  virulent  streptococcus  infection.  The  symptoms 
were  so  severe,  and  so  characteristic  of  profound  shock,  that  the  abdomen  was 
re-opened,  with  the  expectation  of  finding  a  post-operative  hemorrhage.  An- 
other case  died  almost  as  quickly  from  infection  of  the  abdominal  wound  with 
virulent  streptococci.  In  both  instances  the  infecting  organisms  were  found  in 
the  blood  before  death. 

Usually  septicemia  does  not  run  so  rapid  a  course,  but  shows  more  or  less 
variation  of  the  symptoms.  The  temperature  may  remain  uniformly  high  with 
slight  morning  remission,  or  it  may  show  wide  variations.  In  some  cases  the 
temperature  may  run  a  typically  septic  course  for  a  few  days,  then  drop  to  nor- 
mal for  a  day  or  longer,  and  again  resume  its  characteristic  course. 

The  following  are  typical  examples  of  septicemia,  in  one  instance  following 
immediately  after  operation,  in  the  other  some  days  later. 

S.  W.,  3304,  colored,  aged  forty  years.  Diagnosis,  myoma  uteri.  Opera- 
tion, hystero-myomectomy,  Nov.  28,  1894. 

The  operation  was  easy  and  uncomplicated,  and  the  usual  technique  was 
carried  out  in  every  particular. 

Day  of  Operation. — Eeturned  to  ward  at  twelve  o'clock  with  a  good 
pulse,  80  to  the  minute.  No  unusual  symptoms  following  anesthesia  noted 
until  twelve  midnight,  when  the  temperature  was  101-8°  F.  (38*3°  C),  pulse 
1'20  and  weak,  and  she  complained  of  nausea  and  great  pain. 

Second  Day. — From  midnight  until  morning  the  pulse  steadily  failed  ; 
at  4  A.  M.  it  was  138,  small,  and  difficult  to  count.  At  six  o'clock,  worse,  tem- 
perature subnormal,  body  covered  with  cold  perspiration,  extremities  cold,  abdo- 
men slightly  distended,  marked  tenderness  on  ])ressure ;  the  face  was  pinched 
and  drawn,  the  tongue  dry,  and  she  lay  in  a  profound  lethargy.     Under  vigor- 


102 


COMPLICATIONS    ARISING    AFTER    ABDOMINAL    OPERATIONS. 


ous  stimulation  and  application  of  external  heat  the  temperature  rose  to  normal 
and  the  pulse  improved  slightly. 

At  ten  o'clock  the  abdominal  stitches  were  loosened,  followed  by  an  escape 
of  bloody,  purulent  iluid ;  the  stitches  were  then  removed.  Fi-ee  pus  extended 
do\vTi  between  the  layers  of  the  abdominal  muscles  and  a  small  amount  was 
found  in  the  peritoneal  cavity.  Abdomen  irrigated.  A  half  liter  of  salt  solu- 
tion was  infused  into  the  radial  artery.  She  rapidly  decUned  and  died  at  eleven 
o'clock,  twenty-four  hours  from  the  time  of  the  secondary  operation  and  three 
days  after  the  original  operation. 

Abstract  of  Autopsy  Notes . — Autopsy  No.  595.  Anatomical 
Diagnosis:    Laparotomy  wound   for   hystero-myomectomy ;    wound   infection, 


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Fig.  330. — General  Sepsis  from  a  Focus  of  Ixfection  in  the  Vagina  from  a  Perineal  Operation. 
SLxth  day  wound  opened  up  and  drained  ;  death  on  the  twelfth  day.     J.  McG.,  1896. 

acute  iibrino- purulent  peritonitis,  cloudy  swelling  of  organs,  fatty  degeneration 
of  heart,  liver,  and  kidneys ;  hydronephrosis  on  right  side  with  early  atrophic 
changes  in  the  right  kidney. 

On  cuttino;  throuo^h  the  abdominal  wall  in  the  muscles  and  external  to  them 
near  the  line  of  incision,  yellowish-white  pus  exudes.  On  the  parietal  perito- 
neum in  the  neighborhood  of  the  incision  a  fine  dej^osit  of  fil)rin  is  visiljle,  and 
tlie  cellular  tissues  in  front  of  the  bladder  are  markedly  edematous.  The  serous 
coat  of  intestine  is  markedly  congested,  especially  at  points  of  contact ;  fine  and 
coarse  flakes  of  fibrin  are  present  on  small  and  large  intestine,  especially  over  the 
lower  abdomen.     The  upper  part  of  the  abdomen  and  peritoneum  covering  the 


SEPTICEMIA. 


103 


stomach  and  tlie  liver  is 
entirely  free  from  exudate. 
The  cervical  stump  and  the 
peritoneum  covering  it  show 
nothing  to  suggest  this  as 
the  portal  of  entrance  of  the 
infectious  agent.  A  small 
amount  of  clotted  blood  ex- 
ists beneath  the  peritone- 
um, which  was  stitched  back 
over  the  stump. 

Bacteriological 
Examination . — Cover- 
slips  from  pus  in  wound 
and  peritoneal  exudate  show 
cocci  chiefly  in  pairs. 

Cultures  from  the  ab- 
dominal wound,  the  peri- 
toneal cavity,  heart's  blood, 
kidney,  lungs,  spleen,  and 
ureter,  all  show  myriads  of 
streptococci. 

The  following  case  illus- 
trates the  course  of  sep- 
ticemia of  gradual 
onset  and  prolonged 
d  uration : 

Gynecological  No.  3110. 
A.  M.,  white,  single. 

Diagnosis.  —  Pelvic 
abscess,  universal  pelvic  per- 
itonitis. Operation  April 
2,  1894.  Enucleation  of 
both  ovaries  and  tubes  and 
abscess  sac.  Complications, 
dense  adhesions ;  escape  of 
large  quantity  of  fetid  pus 
and  free  hemorrhage  dur- 
ing the  operation. 

Incision  8  centimeters 
(3^  inches)  long ;  the  intes- 
tine was  raised  out  of  pelvis, 
exposing  the  uterus  right 
latei'o-flexed  and  a  large 
convex   cystic   mass   tilling 


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E  ::: 


104  COMPLICATIONS   ARISING    AFTER    ABDOMINAL   OPERATIONS. 

the  whole  posterior  quadrant  and  posterior  part  of  pelvis,  between  the  uterus  and 
the  sacrum.  The  rectum  covering  mass  all  but  small  area — 3  by  1-5  centimeters — 
was  dissected  off  without  injury.  The  abscess  then  broke  with  the  escape  of  250 
cubic  centimeters  of  fetid  yellow  pus,  caught  on  sponges  and  gauze.  The  hole 
was  sewed  up  and  the  enucleation  continued  ;  the  friable  tissue  broke  down,  how- 
ever, and  was  removed  piecemeal,  leaving  an  extensive  bleeding  surface  on  the 
floor  of  the  pelvis.  The  ovarian  vessels  were  ligated  and  the  left  uterine  cornu 
excised  and  the  vessels  controlled  by  transfixion  of  the  broad  ligament  low  down. 
After  checking  the  hemorrhage  the  mass  was  finally  enucleated,  with  the  internal 
iliac  artery  laid  bare  throughout  its  course.  A  pyosalpinx  on  the  right  side  was 
then  removed  from  a  bed  of  dense  adhesions.  A  gauze  drain  was  inserted  after 
thoroughly  washing  out  the  pelvis  and  abdomen  with  normal  salt  solution. 

Second  Day . — Dressings  removed,  covered  with  a  large  amount  of  pale 
hemorrhagic  discharge.  When  the  drain  was  loosened  a  copious  discharge  of 
brownish-red  serum  escaped ;  no  distention  of  abdomen  ;  highest  pulse  100,  and 
temperature  101-4°  F.  (38-5°  C.)  during  the  day. 

Third  Day . — About  three  fourths  of  the  drain  removed,  followed  by  a 
profuse  and  somewhat  oifensive  purulent  discharge.  Highest  temperature  101-4° 
F.  (38-5°  C),  pulse  100. 

Fourth  Day. — About  eight  inches  more  of  the  gauze  removed,  followed 
by  bloody  purulent  discharge.     Temperature  and  pulse  same  as  yesterday. 

The  general  condition  remained  about  the  same  until  the  thirteenth  day, 
when  the  patient  had  a  severe  chill  lasting  half  an  hour,  followed  by  a  tempera- 
ture of  105-6°  F.  (40-8°  C).  The  wound,  although  discharging  freely,  appeared 
healthy.  Nothing  abnormal  detected  by  vaginal  examination,  and  she  com- 
plained of  no  pain.  Temperature  dropped  to  normal,  where  it  remained  until 
the  nineteenth  day,  when  she  again  had  a  severe  chill  with  a  temperature  fol- 
lowing it  of  105-4°  F.  (40-7°  C.)  and  a  pulse  of  144.  Cold  sponging  used  when 
the  temperature  rose.  Yaginal  douches  (1-200)  of  bichloride  of  mercury  solu- 
tion. By  the  afternoon  the  temperature  had  fallen  to  99-3°  F.  (37-3°  C.)  and 
pulse  to  100. 

Profuse  sweating  during  the  pyrexia.  Later  in  the  day  had  some  headache. 
At  midnight  the  temperature  had  risen  to  101-6°  F.  (38-6°  C.)  and  pulse  to  108. 

Twentieth  Da y .—Temperature  at  10  a.  m.  105-5°  F.  (40-7°  C),  pulse 
128.  ■ 

Twenty-third  Da y . — Since  last  note  temperature  has  ranged  between 
104-5°  and  102°  F.  (40-2°  to  38-9°  C.)  and  pulse  from  148  to  116. 

This  varying  temperature  suddenly  dropped  to  101°  F.  (38-3°  C.)  and  pulse 
to  116. 

From  the  twenty-third  to  the  twenty-eighth  day  the  symptoms  gradually 
subsided,  until  tlie  pulse  and  temperature  again  reached  the  normal. 

The  patient,  who  had  up  to  this  time  presented  the  classical  symptoms  of  a 
slow  infection,  now  began  to  improve,  but  five  days  later  had  another  febrile 
reaction,  the  temperature  rising  to  103°  F.  (39-5°  C.)  and  the  pulse  to  120.  The 
following  day  the  temperature  rose  abruptly  from  normal  to  106°  F.  (41-1°  C.) 


PYEMIA.  105 

and  the  pulse  from  90  to  150,  preceded  by  a  severe  chill  and  followed  by  pro- 
fuse sweating,  nausea,  and  vomiting. 

Three  days  later  the  temperature  again  reached  the  normal,  and  continued 
so  until  the  patient's  discharge  on  the  fortieth  day  after  operation.  At  that 
time  she  had  regained  her  appetite  and  showed  all  the  signs  of  a  rapid  return 
to  health. 

The  prognosis  in  septicemia  depends  more  or  less  upon  the  variety  of  the 
organism  causing  it  and  largely  upon  the  immediate  checking  of  its  develop- 
ment by  liberating  the  localized  focus  of  infection  in  which  it  is  generated. 

In  cases  in  which  the  blood  cultures  or  cover-glass  preparations  show 
streptococci  the  prognosis  is  exceedingly  grave,  for  patients  rarely  survive 
such  an  infection. 

The  staphylococeus  aureus,  while  usually  not  dangerous  so  long 
as  it  is  confined  to  a  localized  point,  may  prove  very  virulent  when  it  gains  en- 
trance to  the  circulation. 

The  bacillus  aerogenes  capsulatus  (Welch)  is  also  a  virulent 
organism,  and  usually  produces  death  quickly. 

Under  suitable  conditions  the  p  n  e  u  m  o  c  o  c  c  u  s  and  colon  bacillus 
may  become  fatal. 

The  treatment  advised  in  septic  intoxication  should  be  carried  out  in 
septicemia.  The  greatest  diligence  should  be  observed  in  making  a  thorough 
examination  of  these  cases  in  order  to  discover  early  the  point  of  suppuration 
and  to  open  it  freely. 

Pyemia, — Pyemia  is  a  general  infection  characterized  by  tlie  occurrence  of 
metastatic  abscesses  in  parts  remote  from  the  original  point  of  infection,  and 
associated  with  recurrent  chills  and  intermittent  fever. 

Pyemia  occurs  in  the  course  of  suppurative  processes  and  is  due  to  the  en- 
trance of  masses  of  bacteria  or  of  infected  emboli  into  the  circulation,  which 
lodge  in  other  parts  of  the  body  and  produce  metastatic  abscesses. 

The  symptoms  are  similar  to  those  of  a  slow  septicemia.  The  temperature 
shows  a  wide  daily  excursus,  rising  in  some  cases  from  normal  up  to  103°  or 
105^  F.  (39-5°  to  40-5°  C.)  in  the  afternoon  and  then  falling  during  the  evening 
to  or  near  the  normal.  The  rise  in  the  temperature  is  preceded  usually  by  a 
chill,  which  is  so  regular  in  its  periodicity  as  to  give  rise  to  the  belief  in  some 
cases  that  it  is  of  malarial  origin.  I  see  perhaps  no  more  common  mistake  than 
that  of  ascribing  irregular  temperature  and  recurrent  chills  produced  by  puru- 
lent collections  to  malaria. 

As  the  pyemic  process  increases  in  severity  the  chills  which  may  have  oc- 
curred only  every  two  or  three  days  now  occur  once  or  oftener  daily.  Following 
the  cold  stage  there  is  a  rise  of  temperature,  which  in  turn  gives  way  with  the 
appearance  of  more  or  less  profuse  sweating. 

The  fever  is  always  of  an  intermittent  or  remittent  ty])e,  and  in  some  cases 
the  temperature  may  fall  below  normal  in  the  intervals  between  the  chills.  The 
pulse  in  its  fluctuations  corresponds  to  the  rise  and  fall  of  the  temperature,  vary- 
ing between  100  and  150. 


106  COMPLICATIONS    ARISING    AFTER    ABDOMINAL    OPERATIONS. 

The  patient  is  frequently  nauseated  and  tlie  appetite  is  poor.  In  severe  cases 
delirium  may  be  present,  and  occasionally  tlie  symptoms  of  a  profoundly  ty- 
phoid state  ap])ear  toward  the  end  of  a  fatal  case.  As  the  infection  progresses 
a  characteristic  yellowish  color  of  the  skin  appears,  due  to  the  destruction  of 
the  red  blood  cells.  Albumen  and  casts  usually  appear  in  the  urine,  and  when 
abundant  indicate  metastatic  abscesses  in  the  kidneys. 

The  symptoms  of  metastatic  suppuration  are  varied ;  when  multiple  ab- 
scesses occur  in  the  lungs  they  may  resemble  those  of  a  broncho-pneumonia. 
Suppurative  pleuritis,  purulent  pericarditis,  or  endocarditis  may  arise  at  any 
time  and  cause  a  rapidly  fatal  termination. 

In  acute  pyemia  the  suppurative  process  is  usually  so  rapidly  fatal  that  only 
very  small  necroses  and  abscesses  are  found. 

As  pyemia  is  not  a  primary  but  a  secondary  infectious  process  superimposed 
upon  the  original  localized  infection,  the  prognosis  is  always  exceedingly  grave. 
Cases  so  affected  die  with  few  exceptions.  The  focal  abscesses  forming  in  parts 
inaccessible  to  operation  sooner  or  later  produce  a  fatal  termination. 

Treatment . — Under  the  aseptic  treatment  of  wounds,  pyemia  has  become 
one  of  the  rarest  post-operative  complications.  The  treatment  is  unsatisfactory, 
because  remedies  have  little  or  no  effect  in  staying  its  progress.  Stimulants 
and  carefully  regulated  diet  should  be  prescribed. 

The  wound  from  which  the  pyemic  process  has  arisen  should  be  freely 
opened,  if  accessible,  and  kept  as  clean  as  possible  by  frequent  irrigations  with 
an  antiseptic  solution. 

Pleurisy.  — Pleurisy  is  comparatively  rare  after  celiotomy,  but  it  does  occur 
either  alone  or  as  a  part  of  a  septic  infection.  It  is  much  rarer  than  pneumonia. 
One  form  of  pleurisy  is  the  tubercular,  associated  with  a  tubercular  peritonitis ; 
in  this  case  the  onset  may  be  insidious  and  masked  by  the  peritoneal  symptoms 
so  as  entirely  to  escape  recognition  before  operation. 

Septic  pleurisy,  contrary  to  expectation,  is  associated  usually  with  the  milder 
grades  of  infection  ;  it  appears  four  or  five  days  after  the  onset  of  the  septic 
symptoms  with  an  abrupt  rise  in  the  temperature,  preceded  by  a  chill  and  accel- 
eration of  pulse. 

I  have  seen  five  cases  of  pleurisy  in  over  twelve  hundred  sections ;  four  of 
them  were  mild  and  readily  passed  off.  The  fifth  followed  a  difficult  operation 
for  the  removal  of  large  multinodular,  subperitoneal  cystic  myomata  weighing 
thirty-nine  pounds.  The  patient  made  a  rapid  uncomplicated  recovery,  until 
she  sat  uj)  in  a  chair  by  the  window,  when  she  was  seized  with  severe  pain  in  the 
left  side,  accompanied  with  some  quickening  of  the  pulse  and  a  temperature  of 
102°  F.  and  friction  rales.  A  week  later  there  was  a  relapse  with  effusion.  This 
quickly  subsided,  and  was  followed  by  complete  recovery. 

Symptoms. — The  symptoms  are  usually  quite  characteristic ;  the  patient 
complains  of  difficult  and  painful  breatliing  on  one  side,  accompanied  by  a  short 
hacking  cough.  A  physical  examination  shows  a  diminished  respiratory  move- 
ment and  friction  rales. 

Treatment . — At  the  outset   the   pain   may  be  relieved  by  a  mustard 


PNEUMONIA.  107 

plaster,  a  turpentine  stupe,  or  a  blister.  The  cautery  is  a  still  better  counter- 
irritant,  liglitly  drawn  six  or  eight  times  over  the  surface.  Great  rehef  follows 
the  applicati<m,  and  often  there  is  no  more  pain.  If  the  cough  continues  and 
respiration  is  painful,  adhesive  straps  may  be  used  to  immobilize  the  affected 
side.  I  have  never  seen  a  large  effusion  needing  to  be  tapped.  The  best  pro- 
phylaxis is  to  keep  the  j^atient  well  covered  and  out  of  currents  of  air  durmg 
her  convalescence. 

Pneumonia. — C  a  u  s  e  s  . — Pneumonia  following  operations  arises  from  expo- 
sure of  the  body  during  the  operation,  or  from  the  irritating  effects  of  an  anes- 
thetic, or  from  the  inhalation  of  foreign  matter  (inspiration  pneumonia),  or  from 
the  lodgment  in  the  pulmonary  capillaries  of  septic  emboli  from  a  focus  of  in- 
fection at  the  seat  of  operation.  Pneumonia  is  often  due  to  a  j)rolonged  and 
unnecessarily  free  use  of  the  anesthetic,  and  is  distinguished  from  the  embolic 
variety  by  its  coming  on  within  the  first  twenty-four  hours.  It  follows  the 
administration  of  ether  much  more  frequently  than  of  chloroform.  I  have  only 
once  seen  pneumonia  after  the  use  of  chloroform. 

I  have  seen  examples  of  the  so-called  non-septic  pneumonia  seven  times  in 
seventeen  hundred  cases ;  six  times  the  anesthetic  used  was  ether,  and  once  it 
was  ether  followed  by  chloroform ;  in  this  last  case  the  patient  was  in  good  con- 
dition for  four  days,  when  the  resjjiration  and  pulse  became  rapid  and  the 
tongue  dry  and  brown.  Mucous  and  gurgling  rales  were  heard  over  the  base  of 
the  right  lung,  which  was  consolidated.  The  diagnosis  was  confirmed  at  the 
autopsy. 

In  another  patient  (L.  Y.,  ISTo.  2677,  March  29,  1894)  a  right  ovary  was 
removed  containing  pus,  and  the  uterus  suspended.  On  the  second  day  in  the 
evening  the  rectal  temperature  was  101-1°  F.  (3S-38°  C),  the  pulse  110,  and 
respirations  30.  Bronchial  breathing  was  found  over  the  right  base,  contrast- 
ing with  normal  breathing  on  the  left  side.  Resonance  was  good  on  both  sides. 
There  was  no  nausea.  The  temperature  rapidly  rose  until  the  following  morn- 
ing, when  it  was  lo4-2°  F.  (40-1°  C. ),  with  the  pulse  at  140 ;  on  the  even- 
ing of  the  same  day  the  thermometer  registered  105'4°  F.  (40'7°  C).  The  res- 
pirations were  now  60,  and  the  patient  complained  of  much  pain  on  inspiration. 
Three  hours  later  she  began  to  cough  and  expectorate  rusty  sputum,  and  had 
pain  in  the  chest  on  deep  inspiration.  Her  temperature  continued  the  next  day 
to  104-5°  F.  (40-7°  C.) ;  pulse  144,  dicrotic,  full  and  bounding,  and  respirations 
60.  The  upper  part  of  the  right  lung  now  showed  tyj^ical  signs  of  consolida- 
tion. There  was  no  distention  of  abdomen  or  abdominal  pain.  On  the  fifth 
day  she  was  looking  and  feeling  better,  and  had  little  cough ;  the  lower  lobes 
remained  free ;  temperature  99*2°  F.  (37'3°  C.) ;  pulse  108  and  full ;  constant 
improvement  from  this  time  on.  The  temperature  was  normal  and  the  pulse 
104  the  next  day.  There  w'as  no  abdominal  complication  througliout.  The 
accompanying  temperature  and  pulse  chart  shows  the  characteristic  course  of 
the  disease. 

The  prognosis  of  a  pneumonia  resulting  from  an  anesthetic  is  favorable ;  it 
usually  begins  Avith  a  bronchitis  and  runs  a  typical  course,  soon  reaching  a  crisis. 


108 


COMPLICATIONS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 


I  have  seen  two  deaths  from  pneumonia  after  operation,  one  the  case  of  an 
old  woman  who  had  had  a  severe  attack  of  bronchitis  just  before  the  opera- 
tion, and  to  whom  the  ether  was  given  by  an  inexperienced  man  who  saturated  the 
patient  with  the  drug ;  the  second  followed  a  hysterectomy  for  carcinoma,  and 
was  severe  from  its  onset,  the  patient  dying  on  the  fifth  day  from  heart  failure. 


MARCH 


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.Temperature Pulse 

Fig.  .332. — Chart  showing  an  Abdominal  Operation  Complicated  by  Pneumonia. 

Initial  chill  on  the  third  day  and  crisis  on  the  sixth  day,  with  normal  temperature  on  the  ninth  day. 
Op.,  right  salpingo-oOphorectoniy  and  suspensio-uteri.     March  27,  1894.     L.  Y.,  9572. 

In  septic  cases  embolic  pneumonia  may  arise  many  days  after  the  operation, 
and,  if  mild,  may  terminate  as  an  ordinary  pneumonia.  It  often  appears  also 
simply  as  a  concomitant  of  a  general  septic  infection,  when  it  is  only  one  of  the 
determining  factors  in  producing  a  fatal  issue. 

Symptoms. — In  septic  pneumonia  the  symptoms  come  on  gradually  and 
are  so  closely  associated  with  those  of  the  general  septicemia  that  they  may 
escape  notice.  In  two  cases  of  pyemia  under  my  observation  disseminated 
patches  of  septic  pneumonia  were  discovered  at  the  autopsy,  although  a  careful 
physical  examination  of  the  chest  had  failed  to  reveal  the  fact  before  death. 
The  first  symptoms  usually  appear  four  or  five  days  or  longer  after  the  septic 
process  is  under  way ;  there  is  a  slighi  hacking  cough,  followed  by  muco- 
purulent expectoration,  and  more  or  less  dyspnea,  at  times  distressing  in  its 
severity.     The  character  of  the  pulse,  as  a  rule,  affords  no  information  as  to  the 


ILEUS.  109 

thoracic  disease,  because  it  is  already  rapid  from  tlie  toxemia ;  the  physical  ex- 
amination is  also  unsatisfactory,  for  the  isolated  pneumonic  patches  often  give 
no  demonstrable  signs. 

The  prognosis  is  grave,  as  the  complication  is  but  an  evidence  of  the  general 
infection. 

Treatment . — The  treatment  of  the  simple  lobar  pneumonia  is  expectant 
and  stimulant.  At  first  it  is  well  to  give  relief  by  controlling  the  excessive 
coughing  with  codein  in  doses  of  one  fourth  to  one  half  a  grain  ;  this  allays 
irritation  without  checking  expectoration. 

A  cotton  jacket  to  protect  the  chest  is  essential,  and  should  be  applied  from 
the  first  and  worn  well  into  the  convalescence.  If  there  is  much  pain  in  the 
chest,  the  application  of  turpentine  stupes  and  a  mustard  plaster  will  give  great 
relief.  The  condition  of  the  heart  must  be  watched,  and  at  any  sign  of  failure 
stimulants  must  be  given  freely.  A  whisky  eggnog  affords  both  nutrition  and 
stimulation ;  strychnin  in  the  dose  of  one  fortieth  of  a  grain  should  also  be 
given  every  two  or  three  hours.  On  account  of  the  risk  of  heart  failure,  abso- 
lute rest  in  a  recumbent  position  must  be  enjoined. 

In  septic  pneumonia  the  treatment  should  be  of  a  vigorously  supporting 
nature.  In  addition  to  strychnin  and  whisky  or  brandy,  the  most  nutritious 
food  in  concentrated  form  must  be  given  by  mouth  or  rectum.  Quinin  in  five- 
grain  suppositories  may  be  given  night  and  morning,  with  apparently  good 
effect  in  some  cases. 

Heus. — Ileus  arising  after  operation  is  the  result  of  an  interference  with  in- 
testinal peristalsis  by  one  of  the  following  causes  : 

Either  by  the  strangulation  of  a  knuckle  of  intestine  under  a  band  of  adhe- 
sion, or  by  an  adhesion  of  the  bowel  to  a  raw  surface,  or  by  adhesions  of  the 
bowels  among  themselves  about  a  septic  focus,  or  by  the  incarceration  of  a  loop 
of  the  intestine  through  a  hole  in  the  omentum,  or,  finally,  by  a  simple  twist  of 
a  loop  of  the  bowel  on  its  axis. 

Symptoms . — The  first  sign  of  an  ileus  is  a  griping  pain  more  or  less  local- 
ized over  one  area  of  the  abdomen  ;  it  occurs  in  paroxysms  and  may  recur  every 
two  or  three  minutes,  beginning  gradually  and  increasing  to  a  maximum  of 
intensity  and  then  subsiding.  At  the  onset  of  the  paroxysm  the  patient  as- 
sumes an  expression  of  intense  pain,  and  as  the  acme  is  reached  she  often 
cries  out. 

The  peristaltic  wave  can  be  readily  seen  in  patients  with  thin  or  medium 
thin  abdominal  walls,  which  are  most  distended  above  the  obstruction.  If  the 
obstruction  is  partial,  fiuids  and  flatus  are  forced  through  with  a  gurgling  sound, 
often  audible  at  a  distance  from  the  bed.  The  tense  muscular  contraction  of  the 
peristaltic  wave  can  be  felt  by  the  hand,  giving  at  times  the  sensation  of  a  dense 
fibrous  tumor.  After  a  paroxysm  the  patient  lies  prostrated,  bedewed  with  a 
cold  sweat. 

One  of  the  most  important  symptoms  is  the  ditficulty  of  moving  the  bowels. 
One  or  two  passages  may  be  secured  at  first  from  the  lower  bowel,  but  after  this 
there  is  no  further  evacuation,  and  purgatives  only  increase  the  vomiting. 


110  COMPLICATIONS   ARISING    AFTER    ABDOMINAL    OPERATIONS. 

The  nausea  and  vomiting  are  distressing  from  the  beginning.  The  eon- 
tents  of  the  stomach  are  first  ejected,  and  later,  when  the  vomiting  becomes 
more  frequent  and  violent,  the  ejecta  consist  of  small  quantities  of  bile  and 
mucus,  followed  by  dark  fluid  with  a  strong  stercoraceous  odor,  and  at  last 
by  liquid  fecal  ejecta.  The  abdomen  soon  becomes  swollen,  tympanitic,  and 
tender. 

The  patient  is  rapidly  exhausted,  and  toward  the  last  the  vomiting  may 
cease,  but  the  gynecologist  should  not  be  misled  by  this  delusive  calm,  as  it  is 
usually  but  a  precursor  of  collapse.  At  the  last  the  extremities  grow  cold,  the 
eyes  look  sunken  and  the  face  pinched,  while  the  pulse  becomes  raj)id  and 
shotty. 

If  the  ileus  is  not  speedily  relieved,  the  patient  may  die  either  from  exhaus- 
tion or  from  gangrene  and  j)eritonitis.  Apart  from  a  septic  complication,  the 
patient  may  live  many  days  with  an  ileus,  especially  if  the  strangulation  is  in- 
complete. A  woman  in  a  weakened  condition  before  the  operation  succumbs 
much  sooner  than  one  whose  vitality  is  unimpaired. 

Diagnosis . — That  a  correct  diagnosis  should  be  made  at  the  earliest  pos- 
sible moment  is  of  the  utmost  importance,  as  upon  this  hinges  the  immediate 
active  treatment.  First  of  all,  ileus  must  not  be  confused  with  an  aggravated 
tympanitis,  which  often  gives  rise  to  symptoms  like  those  of  intestinal  strangu- 
lation. In  these  cases  we  find  the  abdomen  swollen  and  tender,  and  the  bowels 
at  first  resist  all  efforts  to  empty  them,  whether  by  mouth  or  by  enema,  and 
there  may  be  too  persistent  nausea  and  vomiting.  If  to  this  we  add  the  intes- 
tinal tormina  common  during  the  first  few  days  after  an  operation,  the  picture 
of  an  ileus  in  its  early  stages  seems  almost  complete.  In  tympanites,  however, 
the  general  pain  is  not  often  severely  paroxysmal  in  character,  the  pulse  is  but 
little  affected,  the  general  condition  is  not  that  of  profound  depression,  and 
there  is  an  entire  absence  of  the  characteristic  facial  expression  of  ileus;  finally, 
persistent  efforts  at  evacuation  of  the  bowels  are  followed  by  a  copious  move- 
ment. Until  this  is  obtained  there  is  sometimes  ground  for  anxiety  as  to  the 
correctness  of  the  diagnosis. 

The  differentiation  between  ileus  and  peritonitis  may  be  easy  or  it  may  be 
diflicult,  especially  since  both  conditions  may  be  present  at  once.  The  ileus  in 
the  case  of  infection  arises  from  the  adhesions  formed  about  a  septic  focus,  which 
represent  a  conservative  effort  to  limit  the  spread  of  the  infection.  The  rise  in 
temperature  and  quickened  pulse  are  here  the  most  marked  evidences  of  the 
complication.  It  must  be  remembered  that  an  ileus  may  be  incomplete,  when 
the  intestinal  contents  will  be  forced  on  in  small  quantities  and  the  bowels  may 
be  slightly  moved  at  intervals.     Such  a  case  is  the  following  : 

Ileus  due  to  incarceration  of  a  loop  of  small  intestine  through  a  hole  in  the 
omentum  due  to  the  Trendelenburg  position. 

The  patient  (M.  C,  2193)  was  operated  upon  Sept.  11,  1893,  for  pelvic  peri- 
tonitis, with  cystic  ovary  and  tubes  bound  down  by  dense  adhesions.  In  placing 
her  in  the  Trendelenburg  position  a  loop  of  bowel  slipped  through  a  hole  in  the 
omentum  and  was  not  discovered  in  closing  the  abdomen.     The  next  day  she 


ILEUS.  Ill 

complained  of  much  pain  in  the  abdomen  and  slight  nausea  :  pnlse,  92.  Two 
days  later,  pain,  distention,  and  nausea ;  bowels  slightly  moved  on  this  and  the 
following  day.  Two  days  later,  pain  not  so  bad  ;  still  vomiting.  Slight  fecal 
odor  of  ejecta,  intense  thirst,  less  tympany  ;  general  condition  improved  ;  pulse, 
100  ;  temperature,  100°  F. 

Sixth  day,  vomiting.  Stomach  washed  out,  bringing  1*5  liters  blackish  fluid  ; 
nausea  relieved.  Abdomen  greatly  distended  in  epigastrium  ;  tongue  red,  dry, 
swollen ;  much  thirst  and  griping  pains ;  small  dark  fluid  movement.  Xinth 
day,  distention  less ;  lavage  daily,  offensive  ejecta  w^th  fecal  odor.  Pain  not 
much,  but  restless ;  flatulence  marked ;  enema  effectual  yesterday  and  to-day. 
Eleventh  day,  almost  constant  pain,  ^vith  frequent  paroxysmal  attacks  not  defi- 
nitely located.  Large  fluid  bowel  movement.  Thirteenth  day,  semi-formed  in- 
voluntary movements.  Sixteenth  day,  several  movements  and  frequent  vomit- 
ing, at  one  time  600  cubic  centimeters  dry  fetid  liquid ;  anxious  expression ; 
much  thirst ;  tongue  red  and  dry.  Seventeenth  day,  abdomen  ojDened  above 
umbilicus,  exposing  greatly  distended  small  intestines.  Tense  band  found  on 
left  side,  cutting  across  bowel  and  extending  down  to  the  left  kidney.  This  was 
divided  and  an  adherent  knuckle  of  intestine  freed  from  the  left  lower  abdomi- 
nal wall,  with  the  escape  of  grumous  fluid ;  counter-puncture  with  drainage  of 
this  area. 

The  patient  died  on  the  twenty -second  day  after  tlie  original  operation,  and 
the  autopsy  revealed  a  loop  of  intestine  25  centimeters  (10  inches)  from  the 
ileo-cecal  valve,  projecting  through  an  omental  hole. 

The  following  is  a  typical  case  of  a  late  ileus  due  to  adhesions  between  the 
small  intestine  and  the  uterus  about  the  stump  of  a  myoma : 

The  abdomen  was  closed  without  drainage.  The  patient  made  an  uncom- 
plicated recovery,  and  the  sutures  were  removed  on  the  seventh  day,  but  on  the 
twelfth  day  she  began  with  a  moderate  tympanites  and  vomiting  at  long  inter- 
vals. Peristaltic  movements  were  noticed  through  the  abdominal  walls,  but 
there  was  no  pain  as  yet.  There  was  a  copious  movement  on  the  eleventh  day. 
The  pulse  was  good,  the  tongue  moist,  the  temperature  normal,  and  the  general 
condition  good.  On  the  next  day  (the  thirteenth)  she  had  pain  in  lower  abdo- 
men, but  seemed  otherwise  quite  well.  Fourteenth  day,  no  movement  since 
the  eleventh  day,  in  spite  of  eight  grains  of  calomel,  soap  and  oil  and  glycerin 
enemata. 

As  the  abdomen  became  more  distended  and  the  pain  increased  with  the 
constant  gurgling,  and  a  marked  bulging  was  felt  in  the  pelvis,  she  was  put  in 
the  knee-breast  position  under  anesthesia,  and  by  compression  and  massage  the 
li(|uid  mass  was  gradually  forced  out  of  the  pelvis  up  into  the  abdomen.  This 
was  followed  by  an  evacuation  and  great  relief  until  early  the  following  morn- 
ing, when  the  symptoms  returned  with  stercoraceous  vomiting. 

I  then  opened  the  abdomen  and  found  numerous  coils  of  small  intestines 
densely  adherent  about  the  pedicle.  The  coats  appeared  gangrenous,  and  were 
torn  in  detaching  them,  necessitating  a  resection  of  15  centimeters  (G  inches)  of 
the  bowel ;  she  died  five  days  later. 


112  COMPLICATIOXS   ARISING    AFTER    ABDOMIXAL    OPERATIONS. 

In  uncomplicated  ileus  the  temperature  is  but  slightly  or  not  at  all  elevated, 
while  in  peritonitis  there  is  a  definite  febrile  reaction. 

In  peritonitis  a  study  of  the  chart  will  usually  show  an  elevated  temperature 
of  longer  duration ;  the  pain  is  not  focal  but  more  diffuse,  and  lacks  the  dis- 
tinctly paroxysmal  character.  The  vomiting  is  also  more  continuous,  and  the 
pain  is  the  result  of  the  act  and  not  independent  of  it. 

Location  of  the  Ileus . — It  is  important  not  only  to  diagnose  the  ex- 
istence of  an  ileus,  but  as  nearly  as  possible  to  locate  its  position.  If  the  stop- 
page is  in  the  rectum  or  in  the  sigmoid  flexure,  this  will  be  evident  by  the  more 
uniform  distention  of  the  abdomen  and  the  less  frequent  retching  and  lessened 
pain.  In  most  cases,  however,  the  ileus  is  due  to  the  pinning  down  of  a  knuckle 
of  the  small  intestines  to  some  point  in  the  pelvis.  In  such  a  case  the  s  t  r  i  c- 
ture  or  the  adhesion  will  be  found  just  below  the  mass  of 
distended  intestines.  The  seat  of  the  obstruction,  therefore,  is  not  to 
be  located  in  the  distended  gurgling  mass  of  intestines,  but  in  the  flat,  quiescent 
part  of  the  abdomen  below  them. 

The  prognosis  in  these  cases  is  always  serious,  but  lessens  in  gravity  the 
earlier  the  diagnosis  is  made.  The  surgeon  is  not  justified  in  opening  the  ab- 
domen before  trying  to  secure  an  evacuation  of  the  bowels  by  mechanical 
agents  unless  the  symptoms  are  so  pronounced  that  he  can  be  certain  of  his 
diagnosis. 

In  eighteen  hundred  abdominal-section  cases,  I  have  reopened  the  abdomen 
four  times  for  ileus ;  two  of  the  cases  recovered  and  two  died.  I  attribute  the 
successful  results  to  the  early  diagnosis  and  operation. 

Treatment . — Prophylaxis  is  the  most  important  point  in  the  treatment,  as 
an  ileus  can  often  be  prevented  by  the  adoption  of  certain  precautions  and  rules 
at  the  time  of  the  original  operation,  which  I  would  epitomize  as  follows : 

1.  All  knuckl  e  adhesions  of  the  small  intestine  which  are  found  must  be 
released. 

2.  Adhesions  binding  the  small  intestines  to  the  pelvic  floor  and  walls  must 
be  freed. 

3.  All  peritoneal  bands  must  be  severed. 

4.  Openings  in  the  omentum  must  either  be  closed  by  suture  or  excised,  or 
the  omentum  tucked  up  close  to  the  colon,  taking  care  at  the  end  of  the  opera- 
tion to  see  that  no  loop  of  bowel  has  slipped  through  it. 

5.  As  far  as  possible,  all  denuded  surfaces  must  be  protected  by  perito- 
neum. 

6.  "When  the  intestines  have  been  lifted  out  they  must  be  replaced  carefully, 
restoring  them  with  their  mutual  relations  undisturbed  ;  this  is  best  done  by  float- 
ing them  in  water  poured  into  the  abdomen. 

7.  A  sound  omentum  must  be  drawn  down  between  the  intestines  and  the 
abdominal  incision  to  protect  the  former. 

8.  A  loop  of  intestine  twisted  on  its  mesentery  must  be  restored. 

9.  The  pelvis  must  be  filled  after  an  operation  as  far  as  possible  by  rectum 
and  sigmoid,  to  the  exclusion  of  the  small  intestines. 


ILEUS.  113 

General  adhesions  binding  loops  of  intestines  together  in  their  normal  mutual 
relations  need  not  be  broken  up,  as  tlie  peristalsis  is  not  interfered  with,  and  the 
extensive  dissection  serves  no  good  purpose. 

One  way  of  covering  in  extensive  raw  areas  on  the  floor  of  the  pelvis,  created 
bj  the  enucleation  of  adherent  tubes  and  ovaries,  is  to  put  the  uterus  over  them 
in  retroposition,  presenting  its  smooth  anterior  face  to  the  intestines  above. 

When  the  elevated  pelvic  posture  is  used  there  is  always  danger  of  a  loop  of 
intestine  dropping  into  an  adventitious  opening  in  the  omentum.  For  this  rea- 
son the  relation  of  the  omentum  and  the  bowels  must  always  be  looked  into  at 
the  close  of  the  operation. 

The  last  steps  before  closing  the  abdomen  are  :  First,  to  lift  the  small  intes- 
tines out  of  the  pelvis,  and  place  in  the  pelvis  the  rectum  and  any  redundant 
sigmoid  flexure,  so  that  if  any  adhesions  form  they  will  neither  produce  discom- 
fort nor  interfere  with  function ;  and  second,  to  see  that  the  small  intestines  are 
arranged  in  the  lower  abdomen  beneath  the  omentum  without  any  twisting  on 
the  mesentery. 

Enemata  and  Medicines . — As  soon  as  the  signs  of  ileus  are  noted 
the  efforts  must  at  once  be  directed  toward  securing  a  free  movement  of  the 
bowels  by  brisk  purgation.  To  this  end  a  large  dose  of  calomel  is  given  by  the 
mouth,  and  high  enemata  of  soap  and  water,  with  a  drachm  of  turpentine  to 
the  pint,  are  given  hourly.  Rochelle  or  Epsom  salts  may  be  given  in  half -ounce 
doses  every  hour  after  the  calomel. 

To  relieve  the  paroxysmal  pains,  turpentine  stupes  on  the  abdomen  are  val- 
uable. If  these  measures  fail  at  first  it  is  best  to  wait  a  few  hours  and  then  try 
again,  in  case  the  patient  is  in  good  condition  and  shows  no  signs  of  weakening. 
If  the  vomiting  is  not  frequent  and  the  patient  can  retain  and  aljsorb  nourish- 
ment, it  is  well  to  wait  longer — even  two  or  three  days.  If,  on  the  other  hand, 
the  signs  are  urgent  and  there  is  a  marked  increase  in  pulse  rate,  with  parox- 
ysmal pains  and  persistent  vomiting  becoming  stercoraceous,  the  indications  are 
for  an  immediate  operation. 

Operative  Treatment . — Every  precaution  must  be  observed  to  pre- 
vent shock.  Chloroform  is  the  best  anesthetic  on  account  of  its  rapid  action, 
and  the  patient  should  be  anesthetized  on  the  operating  table.  Hot  blankets 
must  be  wrapped  about  her  and  the  external  heat  kept  up  by  hot- water  bottles. 
If  the  abdominal  dressing  has  not  been  removed  since  the  first  operation,  it  will 
not  be  necessary  to  cleanse  the  abdomen  again.  Having  noted  as  accurately  as 
possible  the  position  of  the  suspected  ileus,  two  or  more  stitches  are  cut  and  the 
wound  reopened.  If  adhesions  are  detected,  a  larger  opening  should  be  made 
if  necessary  to  facilitate  rapid  work.  The  loops  of  the  intestines  are  drawn  out 
and  laid  on  hot  gauze  and  inspected.  The  oj^erator  must  be  slow  to  conclude 
that  the  ileus  is  due  to  a  slight  twist  in  the  intestines,  only  accepting  this  as  a 
cause  after  a  careful  search  has  failed  to  reveal  more  definite  causes,  such  as 
strangulation  under  peritoneal  bands,  and  adhesions  in  the  pelvis.  All  adhe- 
sions must  be  handled  with  the  utmost  caution  for  fear  of  tearing  off  the  coats  of 

the  bowel. 

48 


114  COMPLICATIONS    ARISING    AFTER   ABDOMINAL   OPERATIONS. 

The  site  of  the  obstruction  if  not  at  once  apparent, 
must  be  sought  in  an  orderly  way  from  below  upward.  The 
first  point  to  inspect  is  the  ileo-cecal  valve.  If  the  small  intestine  is  collapsed 
here  the  bowel  is  then  passed  rapidly  through  the  fingers  until  the  border  be- 
tween the  collapsed  and  the  distended  portion  is  reached,  where  the  cause  of 
the  stricture  will  be  found.  After  removing  the  obstruction  between  the 
collapsed  and  the  distended  parts  of  the  bowels  the  abdomen  must  be  closed  at 
once.     In  one  case  the  obstruction  was  in  the  rectum  just  above  the  ampulla. 

When  the  intestine  is  adherent  to  the  pedicle  of  a  cyst,  to  the  uterine  stump, 
to  the  broad  ligament,  or  to  the  abdominal  walls,  and  there  is  danger  of  tearing 
it  in  the  separation,  the  former  structures  to  which  it  adheres  must  be  sacrificed 
as  far  as  possible  and  left  sticking  to  the  intestine,  rather  than  risk  a  laceration 
requiring  extensive  suturing  of  the  distended  thin-walled  bowel. 

Separation  of  adhesions  between  loops  of  intestines  should  be  done  with  the 
greatest  care,  and,  in  case  an  unavoidable  injury  to  the  muscular  coat  occurs,  it 
should  be  repaired  with  fine  silk  sutures.  The  straight  round  needle  threaded 
with  iron -dyed  silk  is  the  best  for  this  purpose.  If  the  lumen  of  tlie  intestine 
has  been  opened,  it  is  usually  safer  to  put  in  a  gauze  drain  on  account  of  pos- 
sible sepsis. 

If  at  the  completion  of  the  operation  the  patient  is  much  shocked,  the  ab- 
dominal wound  is  best  closed  rapidly  by  silkworm-gut  sutures,  including  all  the 
layers,  and  in  urgent  cases  the  superficial  sutures  between  may  be  omitted. 
The  patient  should  be  put  back  to  bed,  stimulated,  and  kept  warm. 

It  is  not  well  to  hasten  an  evacuation  of  the  intestines  after  such  an  opera- 
tion, as  this  will  often  occur  spontaneously  in  twelve  or  twenty-four  hours,  if 
the  ileus  is  relieved. 

If  the  upper  bowel  has  been  sutured,  most  of  the  alimentation  should  be 
given  by  rectal  enemata  for  five  days  after  the  operation,  and  only  small  quanti- 
ties of  liquid  food  should  be  given  by  the  mouth.  Where  the  rectum,  sigmoid 
flexure,  colon,  or  lower  end  of  the  ileum  are  involved  I  prefer  to  give  all  the 
food  by  the  mouth.  In  any  case  foods  should  be  selected  which  are  almost 
wholly  assimilated  and  leave  almost  no  residue,  or  which  do  not  tend  to  cause 
constipation  or  produce  flatus. 

Nature  is  our  great  assistant  in  these  cases,  for  the  adhesions  between  the 
peritoneal  surfaces  are  rapidly  formed  and  the  injured  parts  protected. 

In  one  case  I  tried  suspending  the  patient  by  the  heels,  hoping  that  gravita- 
tion would  drag  the  adherent  bowel  out  of  the  pelvis.  I  also  powerfully  aided 
the  suspension  by  an  active  bimanual  manipulation  of  the  intestines  through 
the  vagina  and  rectum,  and  rectum  and  lower  abdomen.  The  facility  with 
which  the  adherent  coils  could  be  felt  and  manipulated  was  remarkable,  but 
the  adhesions  were  so  many  and  so  dense  that  no  impression  was  made  upon 
them. 

Stitch-hole  Abscess  and  Suppuration  in  the  Line  of  the  Incision. — Suppuration 
in  the  line  of  the  abdominal  incision  and  stitcli-hole  abscesses  usually  a])pear 
within  ten  days  after  the  operation,  as  the  result  of  an  infection  which  ends  in 


STITCH-HOLE    ABSCESS   AND    SUPPURATION    IN   THE    LINE    OF   INCISION.       115 

the  formation  of  an  abscess  on  one  side  of  the  incision  or  causes  a  separation  of 
the  Hps  of  tlie  wound.  The  defect  in  the  tissue  is  healed  by  a  slow  process  of 
granulation  and  cicatrization,  and  the  result  in  some  instances  is  a  broad, 
stellate,  unsightly  scar. 

These  abscesses  usually  form  in  the  superficial  layers  of  fat,  to  which  the  in- 
fection easily  gains  an  entrance  by  means  of  the  skin  sutures.  Abscesses  located 
close  to  the  surface  become  quickly  localized,  point  into  the  incision,  or  to  one 
side  of  it,  and  discharge.  They  may  give  rise  to  such  symptoms  as  slight  local 
discomfort  and  slight  elevation  of  temperature  (see  chart.  Fig.  333),  but  they  are 
often  overlooked  until  a  little  pus,  sometimes  not  more  than  a  drop  or  two,  is 
found  on  the  dressing.  When,  however,  the  suppuration  occurs  in  the  muscular 
tissues,  forming  a  true  nniral  abscess,  the  symptoms  are  usually  pronounced  and 


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Temperature         Puis 


Fig.  333.— Stitch-hole  Ab.scess  Chaut. 


The  chart  shows  a  practically  normal  course  until  the  sixth  day,  when  a  stitch-hole  abscess  begins  to 
develop.  There  is  a  decided  rise  of  temperature  for  three  days,  followed  by  an  abrupt  decline  when  the 
abscess  ruptures  on  the  ninth  day.  Op.,  hystero-myomcctomy,  complicated  by  double  pyosalpinx.  dyn. 
No.  444L 

progressive,  and,  if  the  infectious  matter  is  not  liberated  early,  may  even  end  in 
death  either  through  the  extent  of  the  abscess  or  by  its  discharge  into  the  peri- 
toneal cavity. 

Grawitz,  from  experiments  upon  animals,  conchided  tliat  a  localized  collection 
of  pus  in  the  abdominal  wall  comnmnicating  with  the  peritoneum  could  ju-oduce 
the  most  fatal  form  of  peritonitis.  Fortunately,  however,  the  abscesses  seldom 
follow  this  course. 

In  a  series  of  seventeen  hundred  abdominal  sections  in  tlio  John.s  Hopkins 
Hospital,  three  deaths  fi-om  peritonitis  were  attributed  to  stitch-hole  abscesses 
communicating  with  the  jieritoneal  cavity. 


116  COMPLICATIONS    ARISING    AFTER   ABDOMINAL    OPERATIONS. 

Causes . — The  limitation  of  this  post-operative  complication  depends  more 
upon  the  care  observed  in  preserving  the  vitality  of  the  tissues  in  the  line 
of  the  incision  and  adjacent  to  it  than  upon  the  mere  exclusion  of  infectious 

germs. 

Unnecessary  handling  of  the  wound,  rough  retraction  of  its 
edges  and  prolonged  pressure  with  metal  retractors,  carelessness 
in  checking  bleeding  in  the  incision,  strangulation  of  large  bits  of 
tissue  by  ligatures,  and  the  use  of  sutures  penetrating  the  skin  in 
closing  the  incision,  all  conduce  to  the  formation  of  stitch  abscess. 

In  a  prolonged  or  difficult  o])eration  the  vital  resistance  of  the  skin  and 
underlying  tissues  are  often  greatly  impaired  by  the  retractors.  Every  autopsy 
upon  serious  operative  cases  in  which  prolonged  retraction  has  been  made  shows 
marked  discoloration  of  the  tissues  not  only  of  the  abdominal  incision,  but  also 
of  the  parietal  peritoneum  adjacent  to  the  incision. 

To  avoid  this  bruising  as  much  as  possible,  the  incision  should  be  long  enough 
to  permit  of  the  freest  manipulation  and  inspection  of  the  field  of  operation 
without  making  undue  pressure  to  expose  it. 

Every  bleeding  point  in  the  incision  must  be  checked,  as,  notwithstanding  the 
greatest  care  observed  in  obliterating  all  dead  spaces,  small  lacunae  are  likely  to 
be  left  behind,  where  blood  may  accumulate  and  offer  a  focus  for  infection.  It 
is  a  good  rule  to  tie  every  actively  bleeding  vessel  as  soon  as  it  is  cut.  Liga- 
tures of  fine  catgut,  which  are  quickly  absorbed,  are  the  best,  and  only 
enough  force  should  be  used  in  tying  them  to  stop  the  bleeding.  Large  areas 
of  tissue  must  not  be  included  in  the  ligature. 

In  one  hundred  and  twenty-five  cases  of  suspension  of  the  uterus,  only  one 
case  showed  even  a  drop  of  pus.  This  is  the  most  favorable  of  all  operations,  as 
all  of  the  conditions  requisite  for  perfect  healing  are  fulfilled,  there  being  a  mini- 
mum of  traumatism,  no  prolonged  handling  of  the  tissues,  slight  bleeding,  and 
little  danger  of  infection. 

A  noteworthy  instance  of  a  profound  depression  of  the  general  system  on 
account  of  a  wasting  or  chronic  disease,  and  a  consequent  failure  in  resistance  to 
infection,  is  seen  in  carcinoma  of  the  uterus.  In  20  per  cent  of  cases  of  abdomi- 
nal hysterectomy  for  carcinoma  in  the  Johns  Hopkins  Hospital,  the  abdominal 
wounds  have  showed  some  degree  of  suppuration. 

Pus  cases,  contrary  to  the  natural  supposition  of  the  clinician,  are  infre- 
quently followed  by  a  stitch  abscess,  which  may  be  due  to  the  imnumization  of 
the  patient  by  the  precedhig  septic  process,  but  more  probably  depends  upon 
the  fact  that  most  cases  contain  no  living  organisms. 

The  active  infecting  germs  in  the  great  majority  of  stitch  abscesses  are  the 
staphylococcus  epidermidis  alb  us  and  the  s  t  a  p  h  y  1  o  c  o  c  c  u  s 
aureus. 

The  impossibility  of  ridding  the  skin  of  the  staphylococcus  albus 
makes  it  a  constant  factor  to  be  feared  as  a  possible  source  of  infection  in  every 
case.  While  it  is  normally  a  feeble  pyogenic  coccus,  under  certain  conditions  it 
may  become  more  actively  pathogenic. 


STITCH-HOLE    ABSCESS    AXD    SUPPURATION    IX   THE    LIXE    OF   INCISION.      117 

Symptoms. — The  first  symptoms  are  usually  observed  from  four  to  five 
days  after  the  operation.  The  patient  complains  of  abdominal  pains,  and  an  ele- 
vation of  temperature  follows,  while  the  pulse  does  not  rise  in  proportion. 

A  severe  rigor  may  be  the  initial  symptom  ;  the  temperature,  instead  of  fall- 
ing normally,  as  shown  in  the  composite  chart  in  Chajjter  XXI,  may  rise  even 
four  or  five  degrees.  The  pain  becomes  more  acute  and  localized  in  a  day  or  so. 
These  symptoms  may  continue  several  days,  when,  if  the  nature  of  the  trouble 
has  not  been  suspected,  a  sudden  relief  is  experienced,  and  on  opening  the  band- 
age, pus  is  found  oozing  in  quantity  from  the  wound  or  a  stitch  hole.  If  the  in- 
fection is  widespread,  several  stitch-hole  abscesses  are  found,  from  each  of  which 
thick  creamy  pus  may  be  squeezed.  If  the  wound  is  inspected  at  the  onset  of 
the  symptoms,  a  circumscribed  red  painful  induration  will  be  found  at  the  focus 
of  infection,  limited  to  one  side  of  the  incision  or  about  a  suture.  Later  it  may 
involve  the  entire  wound  and  even  occupy  an  area  as  large  as  the  open  hand. 

After  the  pus  has  escaped  the  abscess  may  heal  in  a  few  days.  In  other 
cases  the  large  wound  cavity  continues  to  discharge  profusely  for  weeks. 

It  is  possible  (and  this  must  always  be  borne  in  mind)  that  the  discharge,  in- 
stead of  l)reaking  through  on  the  skin  surface,  may  burrow  into  the  peritoneum, 
■where  it  at  once  produces  a  purulent  peritonitis,  and,  on  opening  the  abdomen, 
pus  can  be  seen  oozing  out  through  the  stitch-hole  onto  the  peritoneal  surface 
upon  pressing  on  the  wall. 

All  infections  are  not  so  severe  as  those  just  described,  for  not  infrequently 
there  is  a  small  abscess  in  the  superficial  j^art  of  the  wound,  forming  a  shallow 
pocket  not  larger  than  the  end  of  the  little  finger  and  containing  a  drop  or  two 
of  muco-puralent  discharge.  These  slight  areas  of  infection  are  of  no  moment, 
and  give  rise  to  no  symptoms. 

Diagnosis. — The  diagnosis  is  simple;  inspection  and  palpation  of  the 
abdominal  wall  reveal  a  localized  point  of  induration  sensitive  to  pressure,  ex- 
hibiting the  classical  signs  of  acute  inflammation,  heat,  swelling,  and  pain.  Only 
a  deep-seated  abscess  between  the  muscles  and  peritoneum  can  confuse  the  diag- 
nosis by  simulating  a  localized  infection  about  the  pedicle  of  a  pelvic  tumor. 
The  superficial  induration  and  the  localized  pain  are  sufticient  to  remove  the 
doubt. 

As  the  symptoms  may  not  always  definitely  indicate  the  real  cause  of  the 
pain  and  elevation  of  temperature,  i  t  i  s  i  m  portant  in  all  cases  of 
post- operative  fever  to  search  for  an  abscess  in  the  ab- 
dominal   w^  a  1 1 . 

Treatment. — My  experience  with  various  methods  of  suture  has  con- 
vinced me  that  where  it  is  avoidable  a  penetrating  suture  of  the  skin  should  not 
be  used. 

In  a  series  of  seven  hundred  abdominal  section  cases  I  employed  a  continu- 
ous suture  for  the  j)eritoneum,  and  penetrating  sutures  of  silkworm  gut  for  skin, 
fat,  aponeurosis,  and  muscle.  Since  the  adoption  of  the  method  of  suture  de- 
scribed in  Chapter  XX,  in  which  the  peritoneum,  aponeurosis,  subcutaneous  tis- 
sue, and  skin  are  brought  together  by  separate  layers  of  suture,  I  find  by  a  com- 


118  COMPLICATIONS    ARISING    AFTER    ABDOMINAL   OPERATIONS. 

parison  of  an  equal  number  of  cases  of  celiotomy  closed  in  this  way  that  the 
percentage  of  suppuration  is  far  less  than  in  the  previous  series.  This  improve- 
ment is  no  doubt  due  to  the  use  of  the  subcutaneous  suture  and  the  freedom 
from  strangulation  of  tissues. 

When  the  induration  about  the  infected  area  is  first  detected,  one  or  two 
sutures  in  its  immediate  vicinity  may  be  cut  to  relieve  the  tension  and  to  facili- 
tate the  discharge  of  the  pus. 

Pain  is  relieved  by  the  application  of  dry  heat  and  the  administration  of 
Dover's  powder.  The  bowels  should  be  thoroughly  opened.  If  there  seems  to 
be  any  obstruction  to  the  escape  of  pus,  a  part  of  the  wound  should  be  separated 
Avith  the  forceps,  under  cocain.  Poultices  are  not  advisable  unless  the  area  of 
suppuration  is  large,  because  they  tend  to  break  the  whole  wound  down.  In 
cases  where  there  is  extensive  induration  of  the  tissue  lateral  to  the  incision,  a 
flaxseed  poultice,  made  up  with  1-1,000  bichloride  of  mercury  solution,  may  be 
applied  there  and  kej)t  warm  by  means  of  a  hot- water  bag.  When  the  pus  is 
near  the  surface,  the  inflamed  area  must  be  freely  opened,  either  under  the  in- 
fluence of  cocain  or  of  a  few  whiffs  of  chloroform.  Judicious  pressure  at  the 
side  often  materially  assists  the  evacuation  of  pus. 

The  wound  should  be  washed  out  with  peroxide  of  hydrogen,  followed  by 
a  half  of  one  per  cent  solution  of  formalin,  once  or  twice  daily,  and  later,  if  the 
sides  of  the  incision  tend  to  gap,  they  should  be  gently  drawn  together  with 
adhesive  straps,  until  cicatricial  tissue  has  been  formed. 

Nephritis. — Although  acute  congestion  of  the  kidneys  or  acute  nephritis  are 
often  assigned  as  the  cause  of  death  after  surgical  operations,  I  am  unable  to 
find  a  single  record  of  such  a  case,  either  in  my  clinical  histories  or  autopsy 
records. 

In  many  instances  a  temporary  increase  in  the  amount  of  albumen  and  in  the 
number  of  hyaline  and  granular  casts,  which  have  been  present  before  opera- 
tion, is  noted,  but  in  no  instance  has  the  patient  showed  signs  of  uremia. 

In  many  of  the  fatal  cases  of  peritonitis  in  which  there  was  coincident  kid- 
ney disease  it  is  quite  certain  that  the  renal  lesion  has  been  a  contributory  cause 
to  the  death  by  decreasing  the  patient's  vital  force  and  thus  permitting  a  bac- 
terial invasion  without  resistance.  This  conclusion  is  brought  out  clearly  by  Dr. 
S.  Flexner's  recent  researches  upon  terminal  infections  {A  Statistical  and  Ex- 
perimental Study  of  Terminal  Infections.  Jour,  of  Exper.  Med.,  vol.  i,  No.  3, 
1896).  His  statistics  are  so  striking  that  we  must  henceforth  consider  minutely 
the  question  of  renal  or  indeed  of  any  chronic  visceral  disease  as  a  potent  factor 
in  opening  the  way  for  the  easy  invasion  of  the  tissues  by  micro-organisms.  In 
this  manner  the  renal  disease  may  be  indirectly  the  cause  of  a  fatal  issue. 

Dr.  Flexner  found  in  a  series  of  793  autopsies  made  in  the  Johns  Hopkins 
Hospital  that  255  were  upon  cases  of  chronic  heart  or  kidney  disease,  or  both 
combined. 

In  213  of  these  cases  of  chronic  disease  the  Ijacteriological  examination 
yielded  positive  results,  and  the  infection  thus  demonstrated  was  either  local  or 
general ;  the  local  infections  are  much  more  common  than  the  general,  and  are 


SUPPRESSION    OF  "URIXE.  119 

found  in  a  large  proportion  of  all  cases  of  chronic  Bright's  disease,  arterio-scle- 
rosis,  cirrhosis  of  the  liver,  and  other  chronic  diseases.  Affections  of  the  serous 
membranes  (acute  peritonitis,  pleuritis,  and  pericarditis),  meninges,  and  endo- 
cardium are  the  most  frequent. 

Out  of  29  cases  of  end-infections  in  chronic  Bright's  disease  alone,  26  oc- 
curred in  which  the  bacteria  were  pi'esent  in  some  local  situation  ;  out  of  85 
cases  of  combined  kidney  and  heart  disease  there  were  66  of  local  infection, 
and  out  of  51  cases  of  chronic  kidney  disease  associated  with  some  other  form  of 
chronic  disease,  there  were  35  localized  terminal  infections. 

In  94  of  these  cases  the  mfection  was  found  in  the  following  situations  with 
the  frequency  shown : 

Cases. 

Acute  peritonitis 37 

Acute  pleuritis  (without  pneumonia) 11 

Acute  pericarditis 23 

Acute  endocarditis 19 

Acute  meningitis 4 

In  reference  to  this  group,  it  may  be  said  that  the  micro-organisms  found  at 
the  focus  of  inflammation  appeared  also  in  one  or  more  of  the  organs  of  the 
body,  but  their  distribution  was  not  so  general  as  to  warrant  the  classification  of 
the  cases  among  the  true  septicemias. 

The  varieties  of  bacteria  found  in  the  peritoneum  are  shown  by  the  follow- 
ing analysis,  which  also  exhibits  the  portals  of  entry  of  the  micro-organisms  as 
far  as  they  could  be  determined  with  a  fair  show  of  probability  : 

Acute  Peritonitis. 

Bacteria.  Frequency.  lufection  atrium. 

Streptococcus 8      Intestine 13  times. 

Staphylococcus  aureus  and  albus 9      Laparotomy 13     " 

Micrococcus  lanceolatus 4      Tapping  abdomen 2    " 

Bacilhis  aerogenes  capsulatus 2      Pneumonia 3    '' 

Bacillus  coli  communis 3      Sloughing  myoma  uteri 2    " 

Bacillus  pyocyaneus 1       Pyelonephritis 1  time. 

Bacillus  proteus 1       Doubtful 3  times. 

Bacillus  anthracis 1 

Staphylococcus  cereus  flavus 1 

Streptococcus  and  staphylococcus  aureus. . .  2 

Streptococcus  and  bacillus  coli 1 

Streptococcus,   staphylococcus  aureus,   and 

bacillus  coli 1 

Streptococcus,   staphylococcus  aureus,   and 

undetermined  bacilli 1 

Bacillus  pyocyaneus  and  bacillus  coli 1 

Unidentified  bacilli 1 

Suppression  of  Urine. — Following  all  operations,  especially  the  graver  abdomi- 
nal ones,  there  is  a  marked  diminution  in  the  amount  of  urine  passed  in  twenty- 
four  hours,  as  has  been  shown  in  Chapter  XX;  it  is,  however,  of  little  import 
and  need  occasion  no  alarm,  so  long  as  it  does  not  persist  and  there  are  no  symp- 
toms of  uremia. 


120  COMPLICATIONS    ARISING    AFTER   ABDOMINAL    OPERATIONS. 

After  the  first  twenty-four  or  forty-eight  hours  there  is  a  gradual  increase  in 
the  quantity  up  to  the  normal  about  the  tenth  day. 

In  cases  of  continued  suppression  the  diagnosis  lies  between  nephritis  and  the 
ligation  of  one  or  both  ureters.  If  nephritis  is  the  cause,  the  urine  shows  a  large 
amount  of  albumen  and  a  greater  number  of  casts  than  were  present  before 
operation,  while  if  it  is  due  to  ligation  of  a  ureter,  the  diminution  in  the  urine 
will  be  associated  with  severe  pain  on  that  side  radiating  up  into  the  kidney,  and 
a  microscopic  examination  of  the  urine  will  in  some  instances  show  blood  cells. 
It  is  not  practicable,  on  account  of  the  condition  of  the  patient,  to  catheterize  or 
to  sound  the  ureters  after  operation,  consequently  the  symptoms  and  urinai-v 
examination  afford  the  only  criteria  in  making  a  diagnosis. 

Acute  nephritis  rarely  follows  an  operation  except  where  there  has  been  pre- 
existing disease. 

The  use  of  the  high  salt  solution  enemata  immediately  after  every  abdominal 
operation  has  assisted  very  materially  in  eliminating  this  complication  by  increas- 
ing the  volume  of  urine  and  so  lessening  its  toxic  or  irritant  effects. 

Treatment . — If  the  suppression  of  urine  is  due  to  an  exacerbation  of  a 
chronic  nephritis  no  time  should  be  lost  in  beginning  active  treatment.  The 
saline  purgative  must  be  given  earlier  than  usual,  and  if  there  is  decided  or 
total  suppression  saline  infusions  beneath  the  breasts  should  be  employed. 

The  injection  of  large  quantities  of  salt  solution  into  the  subcutaneous 
tissues  works  marvelously  well  in  some  cases,  because  the  increased  capillary 
tension  of  the  fluid  acting  upon  the  kidney  starts  the  dormant  renal  function, 
and  the  suppression  is  rapidly  overcome.  Hot  water  or  steam  baths  are  not 
practicable  in  surgical  cases,  so  that  remedies  must  be  given  by  the  mouth 
and  endermically.  Pilocarpine  in  one-tenth-grain  doses  every  two  hours,  and 
elaterium  in  one-eighth-grain  doses,  may  be  employed  in  the  most  serious  cases. 

In  suppression  due  to  ligation  of  the  ureter  there  is  but  one  treatment — re- 
opening the  abdomen  and  searching  out  the  ligated  ureter.  Unfortunately,  the 
diagnosis  of  a  ligated  ureter  is  seldom  made  before  autopsy,  and  consequently 
the  necessary  treatment  is  not  applied.  In  my  experience  I  know  that  I  have 
ligated  the  ureters  three  times,  and  the  accident  has  occurred  in  the  hands  of  my 
assistants  twice. 

TTrinary  Fistula.— I  have  only  seen  two  cases  of  urinary  fistula  complicating 
the  convalescence  from  an  abdominal  operation.  In  one  of  these,  after  the  enu- 
cleation of  a  densely  adherent  pelvic  mass,  it  was  necessary  to  pass  a  number  of 
ligatures  with  a  needle  about  bleeding  points  on  the  pelvic  floor.  In  doing  this 
it  is  quite  certain  that  the  left  ureter  was  punctured,  for  a  constant  dribbling  of 
urine  began  througli  the  drainage-tul:>e  which  lasted  for  several  weeks  without 
influencing  the  regular  evacuation  of  the  bladder,  and  finally  ceased  spontane- 
ously. In  the  other  cases,  in  evacuating  a  large  abscess  which  filled  the  lower 
abdomen,  I  found  the  bladder  fully  5  centimeters  above  the  symphysis  and  cut 
through  it  accidentally.  After  evacuation  of  the  abscess  the  thickened  bladder 
walls  were  sutured  together,  but  the  sutures  failed  to  hold  in  the  diseased  tissue 
and  a  urinary  fistula  resulted,  which  was  many  months  in  closing. 


FECAL   FISTULA.  121 

The  occurrence  of  a  fistula  complicating  the  convalescence  will  be  rare  if 
the  abdominal  operation  is  skillfully  performed  and  if  the  operator  examines 
the  entire  field  before  closing  the  wound,  when  any  injury  to  the  urinary  organs 
will  be  detected  and  corrected  at  once. 

One  source  of  fistula  has  been  due  to  cutting  a  ureter  the  end  of  which  was 
then  brought  out  in  the  wound.  This  ought  not  to  occur  any  longer  with  our 
better  knowledge  of  the  relations  of  the  ureters  to  pelvic  tumors  and  inflamma- 
tory diseases,  coupled  with  our  improved  technique  in  ureteral  anastomosis — 
uretero-ureterostomy  and  uretero-cystostomy.      (See  Volume.  I,  Chapter  XIII.) 

Fecal  Fistula. — Fecal  fistula  is  one  of  the  most  annoying  complications  which 
can  arise  after  an  operation,  on  account  of  its  disagreeable  symptoms  and  its 
exhausting  nature.  Its  prevention  usually  lies  within  the  power  of  the  operator, 
and  when  it  occurs  it  is  an  evidence  of  defective  technique. 

The  two  chief  causes  are  injuries  to  one  or  two  or  to  all  the  coats  of  the 
bowel  during  operation,  or  to  necrosis  from  pressure  when  a  glass  drainage-tube 
is  used. 

A  fistula  rarely  follows  injury  to  the  peritoneal  layer  of  the  bowel,  but 
when  both  the  muscular  coats  and  the  peritoneal  layer  are  involved  it  will 
almost  invariably  follow. 

Fistulae  almost  always  occur  in  the  rectum  or  sigmoid  fiexure,  owing  to  the 
contact  of  these  portions  of  the  intestine  with  all  pelvic  infiammatory  masses, 
and  the  necessarj^  traumatism  in  the  enucleation  of  adherent  appendages,  pus 
sacs,  or  tumors. 

Frequently  a  pelvic  abscess  tends  to  evacuate  itself  into  the  rectum,  and  if  an 
operation  is  performed  for  its  enucleation  at  the  time  when  it  is  on  the  point  of 
rupturing,  there  may  be  only  a  thin  septum  between  tlie  abscess  cavity  and  the 
rectum.  In  such  cases  a  fecal  fistula  may  arise  from  the  breaking  down  of  this 
septum  some  days  after  the  operation.  In  cases  in  which  the  fistulous  tract  has 
already  occurred  between  an  abscess  and  the  bowel  it  is  often  almost  impos- 
sible to  close  it  on  account  of  the  dense  adhesions  and  the  friability  of  the  sur- 
rounding tissues. 

All  injuries  of  the  bowel  must  be  sought  out  and  repaired,  and  if  there  is  the 
slightest  danger  of  the  sutured  area  breaking  down,  gauze  drainage  should  be 
employed.  If  such  an  accident  occurs  after  the  abdomen  is  closed  without  drain- 
age, there  is  imminent  danger  of  a  rapidly  fatal  peritonitis  being  induced. 

If  the  injury  has  not  involved  the  mucous  coat,  adhesions  may  form  before 
the  fistulous  tract  opens,  thus  obviating  the  dangers  of  general  peritonitis. 

In  all  cases  where  there  is  danger  of  a  fistula,  drainage 
should  be  employed.  If  there  is  an  opening  in  the  intesthie  which  has 
not  been  closed,  indications  of  the  formation  of  a  fistula  will  usually  be  observed 
within  the  first  twenty-four  to  forty-eight  hours.  On  changing  the  dressings 
the  first  time,  a  faint  feculent  odor  may  be  observed,  which  becomes  marked  in 
character  in  a  few  hours,  and  if  the  intestinal  contents  be  liquid,  feces  may 
escape  into  the  dressings.  In  this  event  the  dressings  should  he  clianged  four 
or  five  times  daily,  and  the  surrounding  skin  washed  with  alcohol  and  anointed 


122  COMPLICATIOXS    ARISIJTG    AFTER    ABDOMINAL   OPERATIONS. 

with  zinc-oxide  ointment.  This  protection  is  especially  necessary  when  the 
fistula  communicates  with  the  small  intestine,  as  its  discharg-e  is  excessively  irri- 
tating. 

During  the  next  four  or  five  days  nothing  should  be  done  beyond  keeping 
the  parts  clean,  in  order  that  the  local  adhesions  should  not  be  disturbed  until 
they  have  securely  walled  off  the  fistulous  tract  from  the  general  peritoneal 
cavity.  At  the  end  of  five  days  the  first  effoi't  should  be  made  to  promote  the 
closure  of  the  fistula  l)y  washing  it  out  with  a  warm  saline  solution  (6  per  cent). 
The  fluid  should  be  injected  into  the  rectum  with  great  gentleness,  and  the 
wound  watched  until  the  solution  wells  up  through  it.  At  least  one  liter  of  fluid 
should  be  injected  so  as  to  cleanse  the  entire  fistulous  area,  removing  any  large 
particles,  and  promoting  the  formation  of  healthy  granulation  tissue.  These 
injections  must  be  repeated  daily,  and  often  after  a  few  days  the  discharge  will 
grow  less  and  the  fistula  gradually  close.  If  the  healing  of  the  tract  is  pre- 
vented by  a  silk  ligature,  this  should  be  sought  out  with  a  blunt  hook  and  re- 
moved at  a  later  date. 

The  fistula  gradually  contracts  until  its  outer  opening  ^jresents  a  puckered, 
roseate  appearance,  the  purplish  red  granulation  tissue  forming  a  pouting  red 
marginal  ring.  When  the  contraction  of  the  tract  reaches  this  point  only  fluid 
feces  escapes,  and  when  the  bowels  are  constipated  nothing  but  gas  escapes. 
The  escape  of  gas  is  most  distressing  to  the  patient  on  account  of  the  odor  and 
the  possible  noise.  Frequently  as  the  discharge  diminishes  the  external  opening 
is  closed  by  a  thin  skin  which  breaks  open  again  as  soon  as  the  intestinal  pressure 
is  increased.  The  deep  ligatures  occasionally  become  dislodged  and  escape,  and 
so  there  is  a  temporary  closure  of  the  fistula,  but,  unfortunately,  it  usually  breaks 
open  again.  In  this  way  the  patient  may  be  disappointed  in  her  hopes  of  recov- 
ery from  month  to  month. 

In  cases  of  a  persistent  fistula  the  first  effort  of  the  surgeon  should  be  to 
determine  the  position  of  the  intestinal  opening  ;  in  order  to  do  this,  inject 
water  into  the  rectum  ;  if  it  appears  quickly  in  the  external  wound,  the  proba- 
bility is  that  the  rectum  is  the  site  of  the  inner  orifice.  This  diagnosis  may  be 
verified  by  gently  passing  a  probe  down  through  the  fistulous  tract  and  then 
feeling  for  the  end  of  it  by  a  finger  introduced  into  the  rectum.  If,  on  the 
other  hand,  the  fluid  appears  slowly  after  the  injection  of  a  half  liter  or  more  of 
water,  it  is  an  evidence  that  the  fistulous  opening  is  higher  up  in  the  sigmoid 
flexure. 

Treatment . — Healing  is  often  promoted  by  the  removal  of  retained  liga- 
tures, and  for  this  purpose  a  crochet  hook  should  be  employed.  When  a  loop 
is  caught  considerable  force  may  be  needed  to  extract  it,  and  if  this  maneuver 
fails,  delicate  pointed  scissors  may  be  used  to  clip  the  loop. 

After  extracting  all  of  the  ligatures  no  further  active  treatment  should  be 
resorted  to  so  long  as  there  are  any  signs  of  improvement.  Peroxide  of  hydro- 
gen is  a  very  useful  agent  in  cleansing  the  tract  and  should  be  used  daily. 

The  use  of  strong  antiseptic  and  astringent  injections  are  frequently  advised, 
but  I  have  failed  to  derive  any  benefit  from  them. 


FECAL    FISTULA.  123 

In  the  process  of  formation  the  fistulous  tract  is  at  first  surrounded  by  deli- 
cate adhesions  binding  the  \'iscera  together  and  walling  it  off  from  the  peritoneal 
cavity.  Later  these  adhesions  become  organized  and  form  a  dense  fibrous  tube 
1  to  2  centimeters  (f  to  ^  inch)  in  diameter,  and  6  to  10  centimeters  (3|^  to  4  inches) 
long,  with  a  lumen  a  few  millimeters  in  diameter  and  lined  with  OTanulation 
tissue,  which  often  presents  the  appearance  of  mucous  membrane.  The  tissue 
of  the  fistula  is  frequently  so  dense  as  to  give  the  sensation  of  cartilage  when 
cut  with  the  knife. 

If  the  fistulous  tract  persists  after  all  local  measures 
have  been  exhausted,  it  should  be  dissected  out  and  the 
bowel  closed  by  suture.  The  treatment  of  an  old  fistula  by  the  radical 
operation  requires  the  complete  remo\'al  of  the  fistulous  channel,  and  the  sever- 
ance of  the  tube  from  its  intestinal  attachment. 

Before  operation  the  abdomen  should  be  cleansed  with  the  greatest  care,  and 
the  intestinal  tract  should  be  evacuated  thoroughly  by  purgatives  and  copious 
eneraata,  given  two  hours  before  operation,  and  again  immediately  before  the 
abdomen  is  cleansed.  Sufficient  fluid  must  be  injected  to  cleanse  the  bowel  so 
thoroughly  that  it  returns  from  the  wound  perfectly  clean.  In  this  way  the  dan- 
ger of  feces  escaping  during  the  operation  is  largely  avoided.  But  to  make 
assurance  doubly  sure,  after  cleansing  the  abdomen  the  fistula  is  packed  with 
iodoform  gauze. 

A  semilunar  incision  8  to  10  centimeters  (3  to  1  inches)  in  length  is  made  2 
to  3  centimeters  to  one  side  of  the  fistulous  tract.  This  exposes  the  intestines, 
and  the  extent  of  their  adhesions  to  each  other,  and  their  relation  to  the  fistula 
may  now  be  studied. 

If  the  omentum  is  adherent  above  the  intestines  it  should  be  tied  off  in  small 
sections  and  released. 

The  length  and  direction  of  the  fistulous  tube,  the  density  of  the  adhe- 
sions, the  point  of  origin,  whether  high  or  low  in  the  intestines,  must  all  be 
determined  carefully,  as  the  prognosis  in  these  cases  depends  much  upon  these 
factors. 

When  the  fistulous  tract  is  long  and  ends  in  the  rectum,  and  there  are 
dense  adhesions  surrounding  it,  the  operation  is  most  diflicult  and  often  results 
in  failure. 

Having  made  a  careful  examination  and  determined  to  continue  the  oper- 
ation, a  second  incision  is  made  on  the  opposite  side,  corresponding  to  and  joining 
the  first,  thus  surrounding  the  fistula  by  an  oval  incision.  Two  stout  silk  liga- 
tures are  now  passed  through  the  end  of  the  tube  and  left  long,  to  serve  as  re- 
tractors, while  tlie  intestinal  adhesions  are  being  separated. 

Bandlike  and  velamentous  adhesions  can  be  severed  with  the  scissors,  while 
those  that  are  dense  and  flat  and  bind  the  fistulous  tract  closely  to  the  intestine 
must  be  dissected  off,  leaving,  if  necessary,  ])art  of  tiie  wall  of  the  fistula  adhering 
to  the  intestine. 

By  observing  the  greatest  precaution  the  fistulous  tract  may  be  freed  down 
to  its  point  of  origin  with  little  or  no  injury  to  the  bowels. 


124  COMPLICATIONS    ARISING    AFTER   ABDOMINAL   OPERATIONS. 

Having  broken  up  the  adhesions,  the  intestines  should  be  packed  away  from 
the  fistulous  tract  with  gauze  pads  to  expose  the  site  of  operation  and  protect 
the  peritoneal  cavity  from  any  intestinal  discharge  which  may  escape  upon 
severing  the  fistula. 

A  ti"ansverse  oval  incision  is  then  made  in  the  gut  around  the  fistulous 
opening.  The  transverse  incision  is  preferable  to  the  longitudinal,  because  it  is 
followed  bv  much  less  contraction  of  the  bowel,  due  to  the  suturing.  If  the 
fistulous  opening  involves  a  large  part  of  the  bowel  it  may  be  necessary  to 
resect  the  bowel  and  do  an  end-to-end  enterorrhaphy. 

The  opening  in  the  bowel  should  be  closed  by  sutures,  in  a  similar  manner 
to  that  described  under  intestinal  injuries  (Chapter  XXXVI). 

If  the  opening  is  large  and  the  first  layer  of  sutures  does  not  close  it  with 
perfect  accuracy,  a  sero-serous  suture  should  be  applied  over  this ;  or  a  loop  of 
intestines,  preferably  the  sigmoid  flexure,  can  be  brought  down  to  cover  the  site 
of  suture  if  it  is  in  the  rectum. 

The  latter  maneuver  is  of  the  greatest  utility,  as  shown  by  an  autopsy  on  a 
patient  who  had  died  of  purulent  peritonitis.  The  case  was  one  of  pelvic  ab- 
scess, which  was  densely  adherent  and  released  with  the  greatest  difliculty.  Dur- 
ing the  enucleation  the  rectum  was  lacerated,  requiring  three  sutures  to  close  it, 
and,  as  an  additional  precaution,  the  sigmoid  flexure  was  drawn  down  over  the 
sutured  area.  At  the  time  of  the  autopsy,  four  days  later,  it  was  found  that 
there  had  not  been  the  slightest  leakage  from  the  rectum,  notwithstanding  the 
fact  that  the  sutures  had  not  held  properly ;  for  the  sigmoid  had  become  ad- 
herent, and  had  effectually  protected  the  rectum  with  its  peritoneal  covering, 
and  so  excluded  the  contents  of  the  intestine  from  the  peritoneal  cavity. 

In  no  case  should  the  lowly  organized  tissues  of  the  wall  of  the  fistula  be 
utilized  in  closing  the  gut. 

At  the  completion  of  the  operation  the  peritoneal  cavity  should  be  carefully 
cleansed  with  salt  solution,  and  a  gauze  drain  laid  down  to  the  point  of  suture  in 
the  intestine ;  if  possible,  the  drain  should  l)e  brought  out  through  the  vagina. 
The  sphincter  ani  should  then  be  thoroughly  dilated  to  facihtate  opening  the 
bowels  as  well  as  to  prevent  any  considerable  accumulation  in  the  lower  bowel. 

Drainage  may  be  dispensed  with  if  the  fistula  is  superficially  situated  and  has 
been  easily  repaired. 

Sometimes  when  the  immediate  result  of  the  operation  is  a  failure  the  new 
granulation  tissue  forming  in  the  canal  will,  after  a  few  days,  completely  close 
the  opening  with  as  good  an  ultimate  result  as  though  the  primary  suturing  had 
held.  The  following  case  illustrates  this  means  of  closure :  J.  H.,  2547,  oper- 
ated upon  at  her  home  in  the  country,  April  7,  1891,  for  densely  adherent  double 
pyosalpinx.  A  glass  drainage-tube  was  inserted,  and  the  patient  remained  in 
bed  two  months  and  a  half.  About  the  third  week  fecal  matter  was  found 
escaping  through  the  drainage  tract.  Since  then  she  has  had  chills  off  and  on 
up  to  the  present  time  (Jan.  30,  1894).  Following  these  attacks  there  was  in- 
tense soreness  in  the  lower  abdomen,  accompanied  by  a  profuse  purulent  and 
fecal  discharge  through  the  fistula. 


FECAL    FISTULA.  125 

Operation  for  fecal  listula,  Feb.  1,  189-1.  At  the  lower  angle  of  tlie  abdomi- 
nal sear  is  a  fistulous  tract  through  which  a  probe  may  be  pa^ed  deep  into  the 
pelvis,  and  above  the  fistula  is  a  prominent  swelling  produced  by  a  hernial  pro- 
trusion. 

The  operation  consisted  in  an  oval  excision  of  the  skin  around  the  fistula, 
including  the  hernial  sac.  The  sac  and  the  indurated  cicatricial  ring  around  it 
were  dissected  out.  The  fistulous  tract  was  then  slowly  detached  and  followed 
down  into  the  pelvis  10  centimeters  (4  inches),  where  it  ended  at  the  rectum. 
The  intestines  could  not  be  separated  from  it  at  this  point  on  account  of  the 
dense  adhesions.  The  fistulous  mass  then  broke  off  close  to  its  entrance  into  the 
gut,  where,  on  account  of  the  dense  indurated  tissue,  it  was  impossible  to  suture 
it  satisfactorily ;  consequently  a  large  gauze  drain  was  inserted,  in  the  hope  that 
new  forming  cicatricial  tissue  would  close  the  fistula.  The  abdomen  was  closed 
with  interrupted  silkworm-gut  sutures  down  to  the  drainage  tract. 

For  four  days  subsequent  to  the  operation  the  patient  did  well,  no  gas  or 
fecal  fluid  escaping  from  the  drainage  tract.  On  the  fifth  a  slight  amount  of 
hquid  feces  appeared ;  this  discharge  persisted  for  nine  days,  and  then  ceased 
entirely,  no  flatus  even  escaping  through  the  fistula,  and  at  the  time  of  discharge 
from  the  hospital  the  abdominal  wound  was  perfectly  healed,  and  it  has  re- 
mained so  since. 

B.  W.  M.,  3108,  admitted  Oct.  15,  1894,  for  intestinal  fistula  following 
hystero-myomectomy  in  1892.  Six  months  after  the  operation  an  abscess  formed 
at  the  lower  angle  of  the  incision  and  ruptured  externally,  and  six  months  later 
a  silk  ligature  came  away.  On  June  29,  1893,  a  number  of  ligatures  were  fished 
out  of  the  fistulous  tract  with  a  crochet  hook ;  in  July  another  bunch  was  dis- 
charged. Several  times  a  discharge  of  fecal  matter  came  through  the  fistula, 
and  in  taking  enemata  the  water  escaped  through  the  opening. 

Operation,  Oct.  16,  1894.  Excision  of  the  fistulous  tract  and  suture  of  the 
bowel. 

The  fistulous  orifice  was  cut  out  by  a  large  oval  excision  of  the  skin  and  the 
old  scar,  opening  through  into  the  abdomen. 

No  adhesions  to  the  abdominal  wall.  An  adherent  loop  of  the  ileum  to  the 
fistulous  tract  was  separated  by  excising  part  of  the  wall  of  the  fistula,  and  leav- 
ing it  on  the  bowel. 

The  detached  outer  end  of  the  fistula  was  now  closed  by  sutures  to  prevent 
the  escajje  of  fecal  contents,  and  when  enveloped  in  gauze,  it  served  as  a  tractor 
to  draw  the  fistula  up,  as  it  was  slowly  dissected  out  of  its  l>ed  of  adhesions. 
Within  the  abdomen  it  hugged  the  antenor  abdominal  wall,  and  then  entered  the 
])elvis  over  the  left  brim  and  passed  over  the  bladder  to  the  sigmoid  flexure,  where 
the  bowel  was  pinned  down  to  the  pelvic  wall,  bladder,  and  the  old  stump  by 
dense  adhesions.  The  fistulous  tract  was  now  dissected  away  from  its  vesical  at- 
tachments, cutting  loose  an  actively  bleeding  area  on  the  vault  of  the  bladder  3 
by  2  centimeters,  but  sacrificing  the  wall  of  the  fistula  and  not  the  bladder.  After 
extensive  dissection  of  the  sigmoid  flexure  from  its  abdominal  adhesions  poste- 
riorly, and  freeing  it  back  to  the  point  where  it  crossed  the  brim  of  the  pelvis,  a 


126  COMPLICATIONS   ARISING    AFTER    ABDOMINAL    OPERATIONS. 

dense  knotted  mass  was  brought  up  and  thought  to  be  dense  bladder  adhesions. 
On  dissecting  this  off  with  a  view  of  sacrificing  tlie  bladder  rather  than  the 
bowel,  the  uterine  stump  was  found  to  have  been  separated  and  not  the  bladder. 

The  stump  was  excessively  vascular,  with  a  cavity  in  the  center,  where  one 
silkworm-gut  suture  and  two  or  three  small  silk  sutures  lay.  The  fistulous  tract 
was  now  found  to  comnuinicate  with  the  rectum  by  an  opening  2  millimeters  in 
diameter,  around  which  for  3  or  4  centimeters  a  band  of  dense  cicatricial  tissue 
existed.  All  of  the  fibrous  tissue  was  trimmed  away  and  the  hole  in  the  rectum 
closed  by  one  mattress  and  two  straight  interrupted  sutures.  The  raw  area 
about  the  fistulous  opening  was  next  whipped  over  with  adjacent  peritoneum  by 
eight  intestinal  sutures.  The  pelvis  was  then  thoroughly  irrigated  and  a  gauze 
drain  inserted  down  to  the  site  of  suture,  and  a  complete  recovery  ensued. 

After  such  an  operation  the  bowels  should  not  be  disturbed  for  four  or  five 
days,  when  a  small  oil  enema,  150  to  200  cubic  centimeters  (5  to  6  ounces),  may 
be  given,  with  a  mild  purgative  pill  or  cascara  sagrada  by  the  mouth,  followed 
by  a  repetition  of  the  enema  in  three  hours ;  this  will  secure  the  desired  effect 
without  unduly  disturbing  the  bowel  and  endangering  the  integrity  of  the  intes- 
tinal suture  by  the  increased  tension. 

Phlebitis. — Phlebitis  in  the  femoral  vein  occurs  as  a  post-operative  complica- 
tion in  a  little  less  than  one  per  cent  of  all  cases.  I  have  had  nine  cases  in  twelve 
hundred  operations,  once  double,  beginning  first  in  the  left  leg  and  then  appear- 
ing in  the  right.  It  does  not  occur  until  two  or  three  weeks  after  the  operation — 
on  the  twenty-second  day  in  five  of  my  cases.  The  latest  phlebitis  I  have  seen 
after  operation  was  on  the  twenty-sixth  day.  In  all  my  cases  the  inflammation 
was  mild  in  character,  and  I  have  never  known  a  death  to  occur  from  this  cause. 
The  real  danger  in  these  cases  is  the  dislodgment  of  an  embolus,  which  may 
plug  the  pulmonary  artery. 

With  this  phlebitis  of  the  femoral  vein  I  would  also  associate  a  group  of 
cases  characterized  by  the  same  symptoms — pain  coming  on  about  two  weeks 
after  operation,  elevated  temperature  and  tenderness,  passing  off  slowly — in 
which,  however,  the  discomforts  are  felt  entirely  in  the  pelvis  on  one  side  and 
there  is  no  evidence  of  any  cellulitis  or  peritonitis  upon  making  a  vaginal  exami- 
nation. I  have  seen  this  affection  then  spread  from  the  pelvic  out  into  the 
femoral  vein  of  the  same  side. 

Symptoms . — The  first  symptoms  are  a  rise  in  the  temperature  and  quick- 
ened pulse,  together  with  a  deep-seated  pain  in  the  line  of  the  inflamed  vessel,  and 
soon  the  leg  becomes  slightly  edematous.  The  vein  becomes  hard,  swollen,  and 
cordlike,  and  has  a  peculiar  knobby  feel ;  its  course  may  be  marked  by  a  dusky 
red  line,  especially  if  the  superficial  veins  are  involved.  The  edema  subsides 
when  the  collateral  circulation  is  established,  often  after  some  weeks.  One 
of  the  most  annoying  symptoms  is  a  lameness  which  may  persist  for  many 
weeks. 

Treatment. — The  local  treatment  consists  in  kee23ing  the  limb  elevated 
and  in  the  application  of  cloths  saturated  with  a  warm  solution  of  lead  water  and 
laudanum,  or  merely  of  warm  fomentations.     A  slight  fiannel  pressure  bandage 


EMPHYSEMA    OF   THE    ABDOMIXAL    WALL.  127 

is  often  of  servdce  in  relieving  pain.  The  Paqiielin  cautery  lightly  touched 
over  the  inflamed  line  often  affords  great  rehef.  Spontaneous  recovery  occurs 
in  from  three  to  eight  weeks. 

Emphysema  of  the  Abdominal  Wall. — This  complication  naturally  calls  for 
anxious  attention  until  its  cause  is  delinitely  settled,  as  the  prognosis  of  this 
condition  is  grave  when  the  bacillus  aerogenes  capsulatus  is  the 
infecting  organism. 

In  two  cases  occurring  in  my  clinic,  reported  by  Dr.  W.  AV.  Eussell,  air  had 
evidently  been  forced  from  the  abdominal  cavity  shortly  after  the  operation 
into  the  tissues  adjacent  to  the  wound. 

Winter  and  Madalener  have  reported  similar  cases  ;  the  latter,  believing 
that  the  emphysema  is  due  to  the  elevation  of  the  jjelvis  during  the  operation, 
recommends  lowering  the  patient  to  a  horizontal  position  before  closing  the 
incision.  Heil  proved  experimentally  that  when  the  dee^Der  layers  of  the  ab- 
dominal wound  were  imperfectly  brought  together  emphysema  might  occur. 

Although  usually  confined  to  a  small  area,  the  emphysema  may  involve  the 
entire  abdominal  wall  and  chest.  The  air  is  forced  out  into  the  tissues  between 
the  skin  and  muscle,  and  never,  as  Leopold  suggests,  between  the  peritoneum 
and  muscle. 

The  following  case  illustrates  this  complication  : 

IS^.  W.  W.,  377^,  aged  thirty-three ;  opei'ation,  Sept.  12,  1895,  suspension  of 
the  uterus  for  retroflexion,  with  the  pelvis  elevated  during  the  operation. 

The  incision  was  closed  by  three  tiers  of  sutures — the  peritoneum  by  a  con- 
tinuous catgut  suture,  the  fascia  by  silver-wire  mattress  sutures,  and  the  skin 
by  a  continuous  subcuticular  catgut  suture.  For  twelve  hours  after  operation 
the  patient  was  violently  nauseated  and  vomited  several  times  ;  the  bowels  were 
well  moved  on  the  fourth  day,  and  there  was  but  slight  pain  during  the  conva- 
lescence. The  highest  temperature  was  99*8°  F.  (37"6°  C),  and  the  pulse  ranged 
between  65  and  90. 

The  dressings  were  changed  for  the  first  time  on  the  eighth  day, 
when  the  right  side  of  the  abdomen  was  found  sensitive  but  normal  in  ajjpear- 
ance,  while  the  left  side  was  uniformly  distended,  sensitive,  and  yielded  a  dis- 
tinct crepitus  on  pressure ;  bubbles  of  gas  could  be  felt  escaping  from  beneath 
the  fingers  wherever  pressure  was  made  ;  the  union  of  the  wound  M'as  perfect, 
and  there  was  no  evidence  of  infection  of  any  kind. 

In  a  few  days  the  emphysema,  which  was  first  noticed  to  the  left  of  the 
wound,  had  completely  surrounded  it,  and  then  it  spread  in  all  directions  under 
the  skin,  upward  to  the  costal  margin,  downward  to  the  symphysis  pubis  and 
Poupart's  ligament,  and  laterally  well  into  the  flanks.  The  skin  did  not  show 
any  change,  nor  was  any  indication  apj)arent  beneath  it.  Cultures  and  cover- 
slips  made  from  a  small  incision  through  the  skin  proved  negative.  "When  the 
patient  left  the  hospital  about  five  weeks  after  operation  her  general  condition 
was  excellent  and  the  emphysema  had  entirely  disappeared. 

Since  the  discovery  (jf  the  gas  bacillus  by  Dr.  Welch  numerous  cases  of  infec- 
tion from  this  source  have  been  reported. 


1^8  COMPLICATIONS   ARISING    AFTER   ABDOMINAL   OPERATIONS. 

The  notes  of  a  ease  furnished  me  by  Dr.  Bloodgood,  resident  snrgeon  in 
the  Johns  Hopkins  Hospital,  are  extremely  interesting  when  compared  with  the 
case  above,  as  this  is  the  first  time  the  gas  bacillus  has  been  found  in  the  abdomi- 
nal wound. 

S.  R.  Surgical  ]\^o.  6102.  Diagnosis,  chronic  appendicitis.  Operation  Feb. 
lY,  1897  ;  removal  of  the  appendix  between  the  recurring  attacks  ;  the  incision 
was  made  through  the  right  rectus  muscle,  the  adherent  appendix  was  dis- 
sected free  and  excised,  and  the  stump  closed  by  suture ;  a  large  gauze  drain 
was  packed  down  to  stump. 

On  the  day  of  operation  the  patient  returned  to  the  ward  with  a  pulse  of 
100  ;  the  evening  temperature  was  99-3°  F.  (37-3°  C.) ;  pulse  96.  At  9.45  p.  m. 
emphysema  was  discovered  in  the  wound,  extending  out  on  the  left  side  of  the 
abdominal  wall,  and  on  the  right  side  into  a  blood  clot  cavity.  The  material 
in  the  cavity  was  chocolate-colored  and  contained  bubbles  of  gas,  and  the  sur- 
rounding muscular  tissue  appeared  necrotic.  Great  numbers  of  gas  bacilli  were 
found  in  the  tissues  and  in  the  blood-clot.  Cover-slips  from  the  clot  showed 
few  leucocytes,  a  few  red  blood  cells,  and  debris  '  the  field  was  filled  with 
large  capsulated  bacilli  of  three  sizes.  Numbers  one  and  two  were  numerous, 
a  few  were  in  chains  of  five. 

Second  day  :  Patient  noisy  and  restless  all  night.  At  4  a.  m.,  sixteen  hours 
after  operation,  the  temperature  had  risen  to  104-4°  F.  (40-2°  C),  pulse  144. 
At  8  this  morning  the  temperature  is  103*5°  F.  (39-4°  C.)  ;  pulse  128  ;  respira- 
tions 36,  now  and  then  intermittent,  entirely  thoracic.  Patient  has  had  no 
nausea  and  vomiting  since  he  left  the  operating  room.  Small  fluid  reddish 
stool ;  cover-glass  preparations  from  stool  show  great  numbers  of  gas  bacilli. 

At  10.30  A.  M.  the  temperature  was  104*8°  F.  (40-5°  C.) ;  pulse  136  ;  respi- 
rations 50.  Wound  opened  and  irrigated  ;  11  a.  m.,  pulse  160,  respirations  60  ; 
12  M.,  temperature  105-6°  F.  (40*8°  C),  pulse  160,  respirations  60 ;  1  p.  m., 
rapidly  failing;  died  at  1*45  p.  m. 

Blood  cultures  taken  immediately  after  death  negative.  Cultures  taken  at 
autopsy  eight  hours  after  death  from  all  the  organs  showed  myriads  of  the 
bacillus   capsulatus   aerogenes. 

Whenever  emphysematous  areas  are  discovered  about  an  abdominal  wound,  a 
small  incision  should  be  made  in  order  to  obtain  cover-glass  preparations  and 
cultures.  If  the  bacillus  aerogenes  capsulatus  is  found,  no 
time  should  be  lost  in  oj^ening  the  wound  and  irrigating 
it   freely    and   packing   with   gauze. 

In  the  case  above  reported  the  wound  was  freely  drained,  but,  iiotNAdthstand- 
ing  this  means  of  exit,  the  infection  proved  rapidly  fatal. 

Sudden  Death. — Embolism  of  the  pulmonary  arteries  stands  in  close  causal 
relationship  to  thrombosis  of  the  pelvic  and  crural  veins.  Since  the  work  of 
Mahler  in  Leopold's  clinic  has  made  clear  the  clinical  signs  and  the  underlying 
pathological  conditions  of  thrombosis  and  embolism  following  gynecological 
operations,  numerous  cases  have  been  observed  and  carefully  studied  post  mor- 
tem, notably  by   Olshausen,  Wyder,  and   Gessner  (see  C.  Ruge's  Festschrift^ 


SUDDEX    DEATH.  129 

Ueber  totliche  Lungenembolie,  etc.).  A  thrombus  is  formed  in  one  of  the  pel- 
vic or  femoral  veins,  is  dislodged,  and  swept  mth  the  circulation  into  the  pul- 
monary artery ;  if  the  thrombus  is  a  small  one  the  attack  is  characterized  by 
precordial  distress,  pain,  and  dyspnea,  associated  with  a  quickened  pulse  ;  after 
one  or  more  of  tliese  attacks  the  patient  may  recover  completely.  Lusk  saw  a 
case  in  which  the  lodgment  of  such  an  embolus  in  the  lung  was  immediately 
followed  by  the  rapid  diminution  of  a  marked  edema  of  the  leg  {Brit.  Med. 
Jour.,  1880,  p.  843). 

"With  the  lodgment  of  a  larger  embolus  the  patient  complains  of  pain  in 
her  side  or  under  the  shoulder  blades,  of  suffocation  and  extreme  precordial  dis- 
tress ;  she  sits  up  in  bed  with  an  anxious  expression,  gasping  for  breath  with  all 
the  auxiliary  respiratory  muscles  brought  into  play,  a  cold,  clammy  sweat  be- 
dews the  face,  she  becomes  cyanosed,  and  the  mind,  at  first  clear,  is  clouded,  and 
she  may  die  in  a  few  minutes,  or  indeed  in  a  few  seconds,  as  in  the  follomng 
case  under  my  care  : 

The  patient  had  been  operated  upon  for  a  papillomatous  ovarian  cyst  and 
extensive  ascites.  The  enucleation  was  a  difficult  one,  and  some  flat  nodules 
were  left  scattered  over  the  floor  of  the  pelvis;  she  made,  however,  in  every  way 
a  most  satisfactory  recovery  until  the  fourteenth  day.  She  had  been  propped 
up  in  bed  during  that  day,  and  had  felt  no  ill  effects  from  it.  When  my  assist- 
ant made  the  rounds  that  night  she  expressed  herself  as  feeling  unusually  well, 
and  consequently  was  in  the  best  of  spirits.  She  went  to  sleep  early  and  rested  • 
well  until  twelve  o'clock,  when  she  awakened,  complaining  of  a  numb  sensation 
in  the  left  leg.  The  nurse,  supposing  that  this  came  from  a  cramped  position 
in  bed,  assisted  her  to  turn  over,  and  rubbed  the  leg  vigorously  for  a  few  sec- 
onds. Suddenly  the  patient  gave  a  sharp  cry,  and  complained  of  frightful 
roaring  in  the  head  and  a  feeling  of  suffocation.  The  pulse  quickly  became 
weak  and  intermittent,  the  breathing  spasmodic,  and  within  a  few  seconds 
she  died. 

No  autopsy  was  made,  but  there  can  be  no  doubt  but  that  the  cause  of  death 
was  the  lodgment  in  the  pulmonary  arteiies  of  a  detached  embolus  from  some 
vessels  about  the  seat  of  operation. 

Whatever  causes  act  to  produce  and  to  dislodge  a  thrombus  are  also  effective 
in  forming  an  embolus.  Thrombi — that  is  to  say,  potential  emboh — are  formed 
by  the  prolonged  pressure  of  pelvic  tumors  upon  the  pelvic  veins,  by  anemia,  by 
marasnms,  notably  that  associated  with  carcinoma,  by  changes  in  the  circulation, 
diminishing  its  force,  particularly  when  due  to  heart  disease,  and  by  a  local 
infection  s])reading  through  the  walls  of  the  veins.  The  immediate  cause  of  the 
dislodgment  of  the  clot  may  be  found  in  an  act  of  coughing,  in  a  sudden  change 
of  posture,  in  straining  at  stool,  etc. 

I  am  inclined  to  think  with  Olshausen  that  an  infection  in  the  proximity  of 
the  vein,  causing  a  phlebitis  with  its  attendant  thrombus,  is  the  real  cause  in 
most  cases,  and  I  would  attribute  less  importance  to  such  conditions  of  the  heart 
as  "  brown  atrophy "  and  "  fatty  degeneration,"  although  cases  have  been  ob- 
fierved  in  association  with  a  warty  heart  or  a  villous  pericardium. 
49 


130  COMPLICATIOXS   ARISING    AFTER    ABDOMINAL   OPERATIONS. 

The  symptoms  in  the  following  case  are  characteristic  of  the  lodgment  of 
emboli  in  the  lungs,  when  death  is  not  produced  suddenly,  but  the  patient  sur- 
vives one  or  more  attacks. 

Thrombi  formed  in  the  large  veins  of  the  broad  ligament  from  which 
emboli  were  detached  at  varying  intervals  and  lodged  in  the  lungs,  producing 
infarcts.  The  dyspnea  was  sudden  in  its  appearance,  and  continued  more  or  less 
aggravated  until  the  patient's  life  was  finally  terminated  suddenly  by  the  lodg- 
ment of  a  large  blood  clot  in  the  pulmonary  arteries.  The  autopsy  notes  bear 
out  the  clinical  symptoms.  Infarcts  and  tumor  metastases  of  varying  ages- 
were  found,  showing  that  the  emboli  were  lodged  at  different  times. 

M.  E.  H.,  'No.  2225,  admitted  Sept.  25,  1893. 

For  over  a  year  she  had  been  feeling  tired  and  languid  and  not  able  to  da 
as  much  work  as  formerly.  Seven  months  before  her  admission  she  ceased  to 
work  on  account  of  increasing  weakness  and  a  heavy,  dull,  pressing  pain  in  the 
left  ovarian  region ;  four  months  later  the  abdomen  began  to  increase  rapidly  in 
size,  when  pain  was  felt  on  the  right  side  as  much  as  on  the  left.  Two  weeks 
ago  her  feet  and  ankles  began  to  swell,  and  about  this  time  great  dyspnea  devel- 
oped, and  she  was  unable  to  lie  down. 

When  first  seen  she  was  pale  and  anemic,  her  complexion  sallow,  and  her 
eves  sunken ;  she  had  lost  flesh  rapidly  of  late.  Bowels  constipated,  defecation 
painful ;  great  dysjDuea,  especially  on  lying  down.  Pulse  small,  quick,  and  wiry. 
Locomotion  difiicult  and  painful. 

The  abdomen  was  found  greatly  distended,  most  marked  to  the  left  of  the 
umbilicus  and  between  the  umbilicus  and  pubes ;  the  skin  was  glossy  and  the 
tumor  mass  irregular ;  the  largest  portion  was  ovoid,  and  extended  from  the  left 
flank  down  to  Poupart's  ligament,  the  second  portion  was  continuous  with  the 
first,  and  extended  from  the  left  flank  to  the  median  line.  Resonance  in  either 
flank,  dullness  and  fluctuation  over  tumor  masses.  Marked  edema  of  the  legs 
below  the  knees. 

Sept.  28,  1893. — Paracentesis  abdominis,  one  liter  of  bloody  viscid  fluid  re- 
moved, and  the  dyspnea  relieved. 

Oct.  8,  1893. — Patient  began  to  suffer  intensely  with  dyspnea  this  morn- 
ing. Pulse  quick  and  irregular,  130  to  11:0.  Face  pale  and  livid.  Great  pain 
in  the  lower  abdomen.  She  can  only  breathe  when  propped  up  in  bed,  and  lies 
with  eyes  shut  and  mouth  open  ;  the  extraordinary  muscles  of  respiration  are  all 
brought  into  action  in  breathing. 

Oct.  lo,  1893. — Abdomen  again  tapped,  removing  300  cubic  centimeters  of 
dark  coffee-colored  fluid.  Dyspnea  still  severe,  but  not  so  intense  as  when  last 
noted. 

Oct.  2oth. — Twenty-three  hundred  cubic  centimeters  of  bloody  viscid  fluid 
evacuated  through  a  small  incision. 

]^ov.  M. — Complains  of  great  shortness  of  breath ;  pulse  130,  weak  and 
thready.     Face  livid,  expression  anxious,  dyspnea  marked. 

Nov.  5th. — Since  last  note  she  has  gradually  failed,  is  restless,  and  the  air- 
hunger  is  intense.     She  died  suddenly  at  Y  p.  m. 


SUDDEX    DEATH.  131 

Autopsy  467  . — Anatomical  diagnosis  :  Sarcoma  of  the  uterus,  secondary 
in  the  king ;  embohsm  of  the  puhnonary  arteries ;  thromboses  of  the  veins  in 
the  broad  Hgaments  and  the  mesosalpinx ;  acute  fibrinous  peritonitis,  acute 
fibrinous  pleurisy,  brouchiectatic  cavities. 

Uterus . — Cavity  13  centimeters  in  depth  ;  on  the  right  side  the  wall  is  2 
centimeters  in  thickness  ;  the  left  side  is  continuous  with  a  large  tumor,  which 
occupies  the  pelvis  and  extends  ■!  centimeters  above  the  umbilicus.  Continuous 
with  the  large  tumor  mass  is  another  12  by  IS  centimeters,  which  occupies  the 
right  side  of  abdomen,  beginning  at  the  free  border  of  the  ribs  and  extending 
down  into  the  pelvis. 

On  section  of  the  tumor,  its  center  is  found  to  be  necrotic  and  sloughing. 
The  upper  tumor  mass  is  nodular,  and  presents  on  section  a  grayish-white 
color.  It  contains  550  cubic  centimeters  of  brownish  fluid  in  which  flakes  of 
necrotic  tissue  are  floating.  The  inner  wall  is  covered  with  sloughing  masses  of 
tissue.  The  veins  of  the  broad  ligament  and  mesosalpinx  are 
greatly  distended  by  thromboses  which  are  generally  red 
and  not  adherent;  occasionally  partly  decolorized  thrombi 
appear. 

Lungs . — The  pleura  is  covered  mth  a  thin  layer  of  fibrin,  and  over  the 
base  of  the  lung  are  areas  of  intense  injection  or  hemorrhage.  On  section,  the 
lobe  presents  a  granular  appearance ;  the  color  is  variegated  and  is  predominat- 
ingly red.  Beneath  the  pleura  are  a  number  of  areas  more  solid  than  the  rest 
and  more  hemorrhagic  in  appearance,  somewhat  wedge-shaped,  with  the  bases 
toward  the  pleura.  In  the  upper  and  middle  jDortion  of  the  lungs  is  an  area 
more  solid  than  the  rest,  distinctly  projecting ;  on  section  its  center  is  hemor- 
rhagic, its  borders  gray,  and  oq  slight  pressure  a  thin  puriform  fluid  escapes. 
Four  centimeters  from  the  base  in  the  middle  line  is  a  circumscribed  globular 
area,  2  centimeters  in  diameter,  composed  of  a  grayish -yellow  friable  tissue 
beset  with  hemorrhages.  On  removing  this  tissue  a  tolerably  smooth  base  ap- 
pears, on  which  a  small  amount  of  connective  tissue  and  vessels  are  visible.  In 
the  base  of  the  U23per  lobe  is  a  circumscribed  area  coming  to  the  surface  of  the 
pleura,  which  is  covered  witli  fibrin  and  small  hemorrhages. 

Pus  can  be  squeezed  from  the  consolidated  area.  The  upper  lobe  is  other- 
wise pale,  slightly  edematous,  and  its  anterior  edge  emphysematous.  The  pul- 
monary artery  supplying  the  upper  lobe  is  occupied  by  a 
thro  m  bus,  the  outermost  parts  of  which  are  moderately  firm,  yellowish  red  ; 
the  interior  is  softer  and  darker.  It  is  only  slightly  adherent  to  the  vessel  wall 
and  can  be  followed  into  the  branches  for  some  distance.  The  branches  to  the 
lower  lobes  are  also  thrombosed.  The  branch  to  the  middle  lobe  contains  a  simi- 
lar thrombus,  and  the  smaller  branches  are  likewise  plugged. 

Left  lung  is  collapsed,  free  from  recent  adhesions,  the  apex  is  retracted,  and 
on  section  of  the  retracted  portion  three  cavities  separated  by  septa  composed  of 
grayish-red  granulation  tissue  and  a  firmer  tissue  apparently  containing  cartilage. 
The  pleura  over  the  area  is  injected  and  the  outermost  zone  of  these  cavities  are 
formed  by  the  pleura,  whereas  beneath  them  in  the  lung  substance  is  a  dense 


132  COMPLICATIOXS   ARISING    AFTER   ABDOMINAL   OPERATIONS. 

grajisli-wliite  tissue.  About  the  middle  of  this  lobe  near  the  root  is  another 
cavity  larger  than  the  others.  In  the  lower  lobe  is  a  circular  consolidated  mass 
the  size  of  a  small  marble,  with  sharp,  distinct  outlines.  The  pleura  over  this 
zone  is  highly  injected,  the  center  opaque.  There  is  a  thrombus  mass  occu- 
pying the  i^ulmonary  artery  distributed  to  the  lower  lobe  similarly  to  the  right 
side. 

Death  from  embolism  has  occurred  after  myomotomy,  removal  of  the  tubes 
and  ovaries  for  myoma,  hystero -myomectomy,  the  extirpation  of  a  carcino- 
matous uterus,  exploratory  incision  for  carcinoma,  ovariotomy,  ventrofixation  of 
the  retroflexed  movable  uterus,  and  curettage  of  the  cancerous  cervix. 

Relatively  the  greatest  number  of  cases  has  occurred  after  myoma  opera- 
tions, which  exhibit  so  large  a  proportion  as  eighteen  out  of  a  total  of  forty- 
three  cases  (Gessner). 

Aside  from  the  clinical  signs  just  detailed,  Mahler  lays  great  stress  upon  a 
persistent  frequency  of  the  pulse  rate,  which  is  out  of  all  proportion  to  the  ele- 
vation of  the  temperature.  With  the  attack  and  the  precordial  pain  and  the 
dyspnea  there  is  usually  a  rise  in  the  temperature  coincident  with  a  rise  in  the 
pulse  rate,  but  the  temperature  drops  sjDeedily  while  the  pulse  remains  high  for 
some  days,  due,  it  would  apj^ear,  to  the  increased  resistance  and  the  elevation  of 
the  blood  pressure  occasioned  by  the  plugging  of  one  or  more  of  the  usual 
larger  circulatory  channels  in  the  lesser  system. 

Treatment . — There  is  no  treatment  for  the  severe  cases,  but  for  those 
which  are  characterized  by  a  succession  of  attacks  and  for  cases  which  present 
any  of  the  signs  of  thrombi,  prophylaxis  is  of  the  utmost  importance. 

"Wyder  even  declares  that  he  will  no  longer  undertake  serious  gynecological 
operations  when  edema  is  present  with  a  high  pulse  rate  and  other  signs  of  a 
recent  thrombosis,  provided  the  general  condition  of  the  patient  will  sanction  a 
postponement. 

The  occurrence  of  such  a  frightful  accident,  even  after  so  simjjle  an  opera- 
tion as  a  ventrofixation,  teaches  anew  the  important  lesson  that  the  surgeon  is 
never  warranted  in  guaranteeing  the  recovery  of  the  patient  even  after  a  seem- 
ingly simple  operation.  Patients  whose  vitality  is  depressed,  and  those  who  are 
anemic,  should  be  watched  with  especial  solicitude. 

The  dangers  are  increased  if  an  edema  before  the  operation  has  given  evi- 
dence of  a  thrombosis. 

The  risk  increases  after  the  operation  when  local  tenderness  and  elevation  of 
temperature  with  a  quickened  pulse  give  evidence  of  the  formation  of  thrombi. 

All  these  cases  should  be  guarded  with  especial  care,  kept  longer  in  bed,  and 
any  active  or  straining  movements  rigorously  guarded  against. 

The  avoidance  of  an  artificial  anemia  produced  by  excessive  loss  of  blood 
during  an  operation,  and  the  use  of  the  subcutaneous  saline  infusions  when  it 
does  occur,  must  also  be  looked  upon  as  important  prophylactic  measures. 

In  case  of  phlebitis  the  limb  should  be  kej^t  well  bandaged  and  quiet,  and 
under  no  circumstances  should  any  vigorous  massage  movements  be  made,  as 
was  done  in  the  first  case  cited. 


DEATH    FKOil    IXTESTIXAL   HEMORRHAGE.  133 

Death  from  Intestinal  Hemorrhage. — lu  three  cases  of  which  I  have  cog- 
nizance death  has  occurred  from  the  liemorrhage  produced  by  an  intestinal 
ulcer.  One  of  these  cases  occurred  in  the  practice  of  Dr.  Thad.  Reamy,  of 
Cincinnati,  another  was  related  to  me  by  ,Dr.  Bela-Wala,  of  Budapest,  and  the 
third  occurred  hi  my  own  clinic,  following  an  operation  for  a  left  pyosalpinx, 
containing  from  20  to  30  cubic  centimeters  of  pus,  produced  by  a  streptococcus 
infection.  The  patient  was  operated  upon  by  Dr.  H.  Robb ;  the  abscess  rup- 
tured in  the  enucleation,  and  she  died  in  four  days  of  an  extensive  intestinal 
hemorrhage  with  a  sejDtic  peritonitis. 

The  autopsy  showed  the  presence  of  a  round  ulcer  of  the  duodenum  18 
millimeters  in  diameter,  with  an  erosion  of  a  small  vein  1  milhmeter  in  diam- 
eter, while  the  large  and  small  intestines  contained  immense  cpiantities  of  soft 
reddish  coagula,  estimated  at  about  2  liters. 


CHAPTER  XXIII. 

TUBERCULAR   PERITONITIS. 

1.  Clinical  characteristics.  ' 

2.  Predisposing  causes. 

3.  Symptoms. 

4.  Diagnosis. 

5.  Treatment.     1 .  Abdominal  section  :  a.  To  remove  focus  of  disease ;  h.  To  remove  fluids ;  c.  To 

release  adhesions.     2.  Drainage  after  operation  for  tubercular  peritonitis. 

TuBEKCULOsis  of  tliG  peritoneal  cavity  is  one  of  the  most  interesting  and  im- 
portant affections  tlie  gynecologist  is  called  npon  to  treat ;  it  is  interesting  on 
account  of  the  difficulty  of  forming  an  accurate  diagnosis ;  it  is  important  on 
account  of  its  frequency  as  well  as  of  the  surjDrisingly  successful  results  of  sur- 
gical treatment.  It  owes  its  specific  character  to  an  invasion  of  the  peritoneal 
cavity  by  the  tubercle  bacillus,  which  has  usually  gained  entrance  from  some 
other  infected  point  acting  as  a  focus  of  distribution. 

This  form  of  tuberculosis  exhibits,  more  than  any  other  gynecological  affec- 
tion, a  remarkable  tendency  to  vary  in  its  morbid  manifestations — for  example, 
in  one  case  the  disease  occurs  in  the  form  of  a  few  tubercular  nodules  scattered 
over  the  peritoneal  surface  of  the  uterine  tube,  or  even  limited  to  the  tubal 
mucosa,  but  from  this  point  in  more  advanced  cases  it  may  spread  out  over  the 
neighboring  peritoneum,  which  then  looks  as  if  peppered  with  little  white  seeds, 
most  abundant  about  the  mouth  of  the  tube.  Spreading  farther  from  such  a 
focus,  the  whole  lower  abdomen  becomes  involved,  and  both  parietal  and  visceral 
pei'itoneum  are  studded  with  nodules,  single  or  aggregated,  from  half  a  milli- 
meter to  several  millimeters  in  diameter. 

The  appearances  on  opening  the  abdomen  vary  greatly,  according  as  more  or 
-less  abundant  adhesions  have  been  formed,  or  according  to  the  amount  of  effu- 
sion of  free  or  sacculated,  bloody  or  serous  fluid  accompanpng  the  peritonitis. 

In  miliary  peritonitis  the  whole  peritoneal  cavity  is  uniformly  studded  with 
discrete  nodules. 

In  the  acute  cases  of  tubercular  peritonitis  there  is  a  noticeaT)le  congestion  of 
the  peritoneum,  with  fresh  vascularized  shreds  of  lymph  hanging  from  the  in- 
flamed surfaces.  The  peritoneum  is  intensely  red  and  thickened,  and  the  neigh- 
boring circulation  markedly  affected,  as  shown  by  the  increased  hemori-hage  from 
small  vessels  in  incising  the  abdominal  wall.  The  thickening  of  the  peritoneum 
may  be  uniform,  and  may  amount  to  several  millimeters  in  chronic  cases,  so  that 
the  organ  looks  like  a  gray  blanket  covering  all  inequalities.  The  skin  around 
the  umbilicus  has  been  noted  to  be  red  and  edematous  in  a  few  instances. 

134 


Fig.  335. — Tubercular  Eight  Tii;ii  wxxa  Tii;eucle  Nodules  distributed  over  the  Surface  of  a. 

Parovarian  Cyst. 

The  ovary  of  this  side  was  not  removed.     San.  Jan.  22,  1897.     Natural  size. 


n  in  e  -n  t  o  ^ 


Fig.  334.— Tubercular  Left  Tube  with  Adherent  Omentum.     San.  Jan.  22,  1897.     Natural  Size. 


TUBERCULOSIS.  135 

The  very  fat  of  the  abdominal  wall  often  betrays  the  nature  of  the  disease, 
before  the  peritoneum  is  opened,  by  its  unhealthy,  pale,  lusterless,  sodden  ap- 
pearance. 

Large  sacculi  of  clear  or  turbid  serous  fluid  are  sometimes  found  in  the  pelvis 
or  in  front  of  the  intestines,  and  smaller  sacculi  may  be  found  walled  off  araons: 
them.  I  have  seen  abscesses  of  varying  size  ;  one  of  the  largest  containing  sev- 
eral liters  of  pus,  was  situated  just  beneath  the  abdominal  wall,  and  extended 
from  the  symphysis  to  the  umbilicus. 

The  omentum  in  a  mild  case  may  be  found  simply  covering  in  the  pelvis,  to 
which  it  adheres  around  the  borders  of  the  superior  strait,  or  it  may  adhere  by 
its  free  border  to  the  anterior  abdominal  wall.  It  undergoes  extraordinary 
changes  in  some  advanced  cases,  contracting  and  thickening  with  the  deposit  of 
tubercular  masses,  until  it  finally  forms  a  thick,  solid  roll  lying  across  the  abdo- 
men from  right  to  left,  attached  to  the  transverse  colon.  The  mass  is  tympanitic 
and  may  seem  quite  movable.  In  a  case  of  Dr.  William  Gardner,  of  Montreal, 
cited  by  Osier  {Johns  Hopk.  Hasp.  Rep,^  vol.  ii,  Xo.  2j,  a  hard  tumor  felt 
down  in  the  right  iliac  and  lumbar  regions  proved  at  the  operation  to  be  the 
omentum. 

The  intestines  often  adhere  lightly  to  one  another  and  to  the  pelvic  struc- 
tures ;  at  other  times  the  adhesions  are  so  extensive  as  to  present  the  peculiar 
appearance  of  a  large  sac,  which  might  easily  be  mistaken  for  a  cyst,  and  the 
attempt  made  to  extirpate  it.  Close  inspection  of  this  sac,  however,  will  reveal 
fine  lines  where  the  coils  of  intestines  are  agglutinated,  often  distinctly  marked 
out  by  a  little  deposit  of  lymph,  looking  like  a  white  thread  on  the  red  surface. 
I  have  seen  this  line  everywhere  parallel  to  the  line  of  union  of  the  intestinal 
coils,  but  a  few  millimeters  distant  from  it,  showing  that  the  intestines  had  been 
pulled  away  by  peristaltic  movements,  after  its  formation. 

In  event  of  any  uncertainty  the  tnie  nature  of  this  sac  may  be  revealed 
upon  striking  a  sharp  blow  with  a  finger,  which  sets  up  a  faint  vermicular 
motion. 

In  a  case  of  extensive  tul)ercular  disease  which  I  saw  in  18S5, 1  was  much  em- 
barrassed upon  opening  the  aljdomen  and  removing  the  fluid  to  find  a  large  red 
sac  filling  the  lower  abdomen,  with  its  pedicle  apparently  attached  to  the  poste- 
rior abdominal  wall.  A  close  inspection  revealed  the  sinuous  white  lines  spoken 
of,  on  the  surface,  and  on  tapping  the  sac  lightly  with  the  finger  a  distinct  peri- 
staltic wave  was  started,  showing  that  it  consisted  of  the  entire  mass  of  the  small 
intestines.  The  fluid  accumulated  in  the  peritoneal  cavity  was  drained  out,  and 
the  patient  recovered  and  is  living  to  day. 

Tuberculosis  of  pelvic  origin  may  be  associated  with  a  variety  of  other  dis- 
eases. In  one  of  my  cases,  for  example,  there  was  a  miliary  tuberculosis  of  the 
left  tube,  and  a  dermoid  cyst  of  the  right  ovary  3  centimeters  in  diameter.  In 
another  case  there  was  an  ovarian  cyst  on  the  left  side  about  12  centimeters  in 
diameter  (5  inches),  and  an  extensive  peritoneal  tuberculosis,  covering  the  outer 
surface  of  the  cyst  as  well,  with  effusion.  In  still  another  case  a  tuberculous 
tubo-ovarian  abscess  contained  gonococci. 


136  TUBERCULAK    PERITOiN'ITIS. 

Etiology . — The  cause  in  all  cases  is  the  invasion  of  the  peritoneum  by 
the  tubercle  bacillus,  which  finds  in  the  serous  surface  a  suitable  pabulum  for 
germination.  The  mode  of  invasion  is  often  difficult  to  determine.  In  the 
cases  seen  bj  the  gynecologist  the  proximal  avenue  is  usually  by  the  uterine  tube, 
and  in  many  instances  it  is  quite  clear  that  the  disease  has  reached  the  tube  by  the 
vagina  and  uterus,  because  the  tubercular  lesions  are  also  found  in  these  organs. 


Fig.  830.— General  Tubercular  Peritonitis. 

Showing  the  way  in  which  the  uterus,  tubes,  broad  lioraments,  and  ovaries  are  studded  with  tubercles. 
There  is  also  a  commencing  tuberculosis  of  the  tubal  mucosa.  The  case  is  also  complicated  by  a  coincident 
epithelioma  of  tlie  cervi.x.     July  2i,  IS'Jo,  No.  813.    %  natural  size. 

Cases  of  dissemination  of  the  tubercles  over  the  peritoneum  may  also  occur 
from  a  broken-down  mesenteric  gland,  or  by  extension  from  tuberculous  intes- 
tinal ulcers. 

Miliary  tuberculosis  involving  all  the  organs  of  the  body  may  arise  from  a 
cheesy  thoracic  gland  opening  into  a  vein  and  distributing  its  products  through- 
out the  whole  system.     With  this  affection  we  have  nothing  to  do. 

Predisposing  causes  are  not  easy  to  determine ;  in  a  series  of  sixteen  cases 
of  my  own,  the  family  history  was  good  in  twelve,  tuberculous  in  two,  and  can- 
cerous in  two. 

A  previous  depressed  state  of  health  does  not  seem  to  be  such  an  important 
factor  as  one  would  naturally  expect,  for  out  of  nineteen  of  my  cases,  fourteen 
were  well  until  taken  with  the  present  illness,  and  but  five  stated  that  they  were 
previously  in  ill  health. 

There  is  also  a  wide  variance  in  tlie  histories  that  are  presented  as  to  the 
time  of  onset.  Six  patients  out  of  twenty-one  definitely  dated  their  illness  from 
a  miscarriage  or  a  labor,  two  others  fixed  the  Ijeginning  of  their  disease  at  a  pe- 
riod between  two  and  three  weeks  before  applying  for  relief,  six  others  dated  it 
back  some  time  between  three  months  and  a  year,  and  six  more  from  one  to 
seven  years  ;  one  could  not  fix  any  time. 


TUBERCULOSIS.  137 

Pregnancy  shows  a  definite  causal  relations liip  which  has 
not  been  adequately  noted.  Twenty-eight  per  cent  of  my  cases  definitely  dated 
their  ailment  from  a  miscarriage  or  a  labor. 

Of  the  married  women,  2941  per  cent  remained  sterile  and  11-76  per  cent 
miscarried  every  time ;  41'17  per  cent  were  sometimes  delivered  at  term  and 
sometimes  had  miscarriages,  while  but  17"6i  per  cent  always  went  to  term.  To 
the  ten  child-bearing  women  thirty-five  children  were  born — an  average  of  3*5 
each — while  nine  women  had  twelve  miscarriages ;  one  of  the  mothers  bore 
eight  children. 

The  following  history  of  a  patient  whom  I  saw  in  consultation  with  Dr.  L. 
M.  Sweetnam,  of  Toronto,  is  quite  characteristic  of  this  group  of  cases :  A 
woman  in  the  twenties,  previously  in  perfect  health,  had  a  mechanically  induced 
abortion  between  the  second  and  third  months ;  within  a  month  she  went  to 
bed  with  peritonitis,  and  remained  there  four  weeks.  For  a  year  after  this  she 
suffered  abdominal  pain  in  walking,  and  had  frequent  elevation  of  temperature 
while  going  about,  sometimes  rising  over  105°  F.  (40°  C).  ^Vlien  the  abdomen 
was  opened  the  intestines  were  found  extensively  and  densely  adherent,  and 
there  were  two  pus  sacs  present.  Nothing  was  removed,  but  4  grams  of  iodo- 
form were  introduced  and  distributed  through  the  abdominal  cavity,  and  for 
twelve  months  the  temperature  remained  practically  normal.  Eight  or  nine 
months  after  this  the  patient  had  a  subacute  left  pleuritis,  and  three  months 
later  she  died  of  typical  acute  tubercular  meningitis. 

The  tendency  of  the  disease  is  either  to  run  an  acute  course  and  subside, 
leaving  behind  pelvic  adhesions  involving  tubes,  ovaries,  and  uterus,  or  to  as- 
sume a  chronic  phase  ^yit\l  exudation  or  the  production  of  fibroid  tissue. 

The  fact  must  not  be  lost  sight  of  that  some  of  the  cases  which  reach  the 
surgeon's  hands  have  passed  the  period  of  danger  from  extension  of  the  tuber- 
culosis, and  the  relief  desired  is  for  the  sequelae  of  the  disease. 

Contrary  to  exijectation,  grave  tubercular  disease  of  other  organs  is  not  com- 
mon, not  even  of  the  lungs — in  fact,  the  presence  of  tubercular  peritonitis  of 
pelvic  origin  seems  often  to  ajfford  an  immunity  to  tuberculosis  elsewhere.  I 
have  seen  but  four  cases  of  extensive  tubercular  pelvic  disease  associated  with 
advanced  lesions  hi  the  lungs,  two  of  them  in  a  series  of  twenty-two  cases,  and 
it  was  not  possible  in  either  case  to  determine  upon  the  primary  focus  of  in- 
vasion. In  one  of  my  cases  I  drained  an  encysted  tubercular  peritonitis  and 
the  patient  recovered,  and  died  a  year  later  of  phthisis. 

I  do  not  here  refer  to  cases  of  tubercular  peritonitis  arising  late  in  the  course 
of  pulmonary  or  intestinal  phthisis,  for  these  do  not  often  come  into  the  hands 
of  the  gynecologist  for  treatment. 

Only  one  patient  had  pleurisy,  although  i)lenrisy  ^vith  or  without  efi'usion 
has  been  frequently  noted  as  a  common  complication.  I  have  never  seen  either 
lupus  or  tubercular  joints  or  tubercular  rectal  disease  associated  with  peritoneal 
tuberculosis. 

A  markedly  predisposing  factor  is  found  in  the  age  of  the  patient.  The 
young  and  the  old  are  comparatively  immune  from  tubercular  peritonitis  of 


138  TUBERCULAR    PERITOISriTIS. 

pelvic  origin,  although  it  is  quite  common  in  young  children  from  other  sources. 
The  average  age  of  twenty -nine  of  my  cases  was  27'59  years,  the  oldest  being 
forty-seven,  and  the  youngest  a  black  girl  of  seventeen ;  the  youngest  white 
woman  was  thirty. 

Dr.  William  Osier  {Johns  Hopk.  Hasp.  Rep.,  vol.  ii,  No.  2.  p.  TO)  has  ana- 
lyzed 346  cases,  male  and  female,  according  to  age,  with  the  following  result : 
Under  ten,  27;  between  ten  and  twenty,  75;  from  twenty  to  thirty,  87;  be- 
tween thirty  and  forty,  71  ;  from  forty  to  fifty,  61 ;  from  fifty  to  sixty,  19 ; 
from  sixty  to  seventy,  4 ;  above  seventy,  2. 

It  still  remains  a  question  whether  race  exerts  an  influence  on  the  relative 
frequency  of  the  disease.  In  my  clinic  of  thirty  beds,  in  which  six  were  occu- 
pied by  blacks,  twenty-nine  cases  are  recorded  in  the  course  of  five  years,  of 
which  eleven  were  in  the  blacks. 

It  would  appear  from  an  analysis  of  my  cases  that  there  is  some  difference 
in  the  average  age  at  which  the  disease  attacks  the  two  races:  out  of  my  twen- 
ty-nine cases,  the  average  age  of  the  white  women  was  29*55  years,  while  the 
average  age  of  the  blacks  was  but  25'63.  Sixteen  of  the  twenty-nine  cases  were 
between  twenty  and  thirty  years  of  age. 

The  general  appearance  of  many  of  these  tubercular  women  on  admission  to 
the  hospital  was  a  striking  contradiction  of  the  opinion  that  a  tubercular  patient 
carries  about  with  her  the  impress  of  her  disease  in  a  pale,  anxious  look  and  an 
emaciated  frame.  Quite  the  contrary  may  be  true.  For  example,  one  of  the 
most  robust,  blooming  young  women  I  have  ever  seen  had  so  extensive  a  pelvic 
tuberculosis  as  to  necessitate  the  removal  of  uterus,  ovaries,  and  tubes.  Dr. 
Osier  has  dwelt  with  especial  force  upon  the  latency  of  the  process  in  some 
cases  when  "  the  eruption  takes  place  so  slowly  and  so  painlessly  that  the  patient 
may  not  have  presented  a  single  symptom  of  abdominal  disease."  In  one  case 
a  man  died  with  a  strangulated  omental  hernia,  and  an  entirely  unsuspected 
extensive  fibrous  tubercular  peritonitis  was  found  on  autopsy.  A  girl  died  of 
typhoid  fever,  and  at  the  autopsy  an  extensive  tubercular  peritonitis  was  found. 

One  of  my  own  patients  (B.  M.,  14),  forty-two  years  old,  had  been  ill  ever 
since  her  last  child  was  born,  five  years  before ;  for  a  year  she  had  noted  an 
abdominal  tumor  growing  in  the  left  side.  Her  poor  health  was  associated 
with  a  winter  cough  and  j^leurisy  on  the  right  side.  I  operated  Oct.  18,  1889, 
and  removed  a  left  ovarian  tumor  as  large  as  a  cocoanut  and  a  right  ovarian 
cyst  as  large  as  a  lemon.  The  ovarian  tumor  and  the  entire  peritoneum 
were  covered  with  miliary  tubercles,  the  intestines  were  matted  together  in 
places,  and  there  were  500  cubic  centimeters  of  free  fluid  in  the  peritoneal 
cavity.  The  nodules  were  firm  and  hard  and  some  of  them  pigmented,  and  a 
microscopic  examination  showed  that  they  were  tubercular.  She  made  a  com- 
plete recovery,  and  died  later  of  a  malignant  disease  in  the  pedicle  of  the 
tumor. 

Sixteen  out  of  twenty  patients,  or  80  per  cent,  are  noted  to  have  been  in 
good  condition  with  a  good  color,  while  but  five,  or  20  per  cent,  were  poorly 
nourished,  anemic,  and  sickly. 


TUBERCULOSIS.  139 

The  percentage  of  ill-nourislied  patients  among  the  negroes  was  larger  than 
among  the  whites,  holding  a  relation  of  25  per  cent  to  16*66  per  cent. 

S  J  m  p  t  o  m  s . — P  a  i  n  is  the  most  constant  symptom,  and  is  referred  to  the 
back,  lower  abdomen,  and  pelvic  organs ;  it  is  usually  persistent  and  associated 
with  menstrual  exacerbations.  It  varies  all  the  way  from  a  continuous  ache  or 
soreness  to  intense  suffering,  compelling  the  patient  to  stay  abed.  One  patient 
will  complain  of  a  sharp  and  shooting  pain  with  a  sense  of  bearing  down,  in- 
creased by  walking  or  exertion ;  another  speaks  of  a  sharp,  sliooting  pain  during 
the  monthly  period,  and  at  other  times  a  dull  soreness  extending  into  tlie  thighs, 
with  giddiness. 

The  abdomen  is  often  distended  with  wind,  and  the  distention  may  be  per- 
manent or  it  may  recur  at  intervals ;  there  is  often  also  nausea  and  vomiting.  I 
have  been  told  by  some  women  that  they  were  suffering  from  "  inflammation  of 
the  stomach."  The  blacks  complain  of  a  "  misery  "  in  the  pit  of  the  stomach. 
Intense  pain  in  the  ovarian  regions  and  severe  headaches  are  frequent. 

With  the  pain  there  is  always  a  tenderness  of  the  lower  abdomen,  so  that  the 
patient  can  not  endure  deep  pressure  nor  stand  erect  with  comfort.  They  of 
necessity  adopt  the  posture  and  gait  which  are  characteristic  of  the  chronic  lower 
abdominal  inflammations. 

Poor  appetite  or  dyspeptic  symptoms  were  complained  of  by  four  fifths  of 
my  cases. 

Fever  is  sometimes  absent  and  sometimes  j) resent,  al- 
though the  patients  not  infrequently  complain  of  "  chills  and  fever,"  with  chilly 
sensations  and  sometimes  night  sweats.  A  persistent  slight  elevation  of  tem- 
perature between  99°  and  100°  is  often  seen,  and  more  rarely  a  decided  eleva- 
tion from  102°  to  104°  in  the  acute  cases. 

Constipation  occurs  in  one  half  the  cases ;  20  per  cent  complain  of  pain  in 
defecation,  which  may  be  attributed  to  the  disturbance  of  the  inflamed  adherent 
surfaces  during  the  act  of  straining. 

Pain  in  urination  is  the  most  characteristic  of  all  the 
symptoms.  Out  of  20  cases,  only  3  were  free  from  it ;  14  complained  of 
burning  pain  during  micturition ;  in  8  of  these  frequency  of  urination  was 
added  ;  in  3  others  there  was  incontinence  with  pain. 

The  menstrual  history  is  noted  in  22  cases ;  2  of  these  had  amenorrhea,  2 
scanty  flow,  and  in  3  the  flow  was  more  jjrofuse  than  formerly.  Dysmenorrhea 
was  specially  complained  of  by  but  4  cases,  while  in  9  no  change  was  noted  at 
all.  Leucorrhea  was  profuse  in  8  out  of  15  cases ;  in  3  it  was  of  an  irritating 
character,  and  in  3  othei's  the  patient  complained  of  the  bad  odor.  There  was 
a  continuous  blood-stained  discharge  in  one  instance. 

Diagnosis. — In  attempting  to  make  a  diagnosis  of  tubercular  peritonitis 
before  operation  it  is  at  once  evident  that  those  symptoms  most  reUable  and  char- 
acteristic of  tuberculosis  of  other  organs  fail  us  here. 

In  many  instances  the  healthy  appearance  of  the  patient  and  the  good  fam- 
ily history  disarm  any  suspicion  as  to  latent  tuberculosis  in  the  mind  of  one  not 
specially  familiar  with  its  peculiarities. 


140  TUBERCULAR    PERITONITIS. 

In  tliree  classes  of  cases,  however,  the  diagnosis  is  not  difficult  to  make : 

First,  where  extensive  pulmonary  disease  is  associated  with  pelvic  inflamma- 
tory masses  the  presumptive  diagnosis  is  that  the  abdominal  trouble  is  similar  in 
character. 

Second,  where  a  persistent  uterine  discharge  or  uterine  curettings  are  found 
to  contain  tubercular  foci,  the  inflammatory  disease  lateral  to  the  uterus  may 
confidently  be  asserted  to  be  similar  in  its  origin. 

Third,  where  there  is  pelvic  inflammatory  disease  associated  with  irregular, 
ill-defined  masses  with  fluctuation  in  the  lower  abdomen,  and  the  latter  are  noted 
at  subsequent  examinations  to  have  changed  their  relations  to  some  extent,  the 
diagnosis  will  be  tuberculosis. 

The  utility  of  tuberculin  as  a  means  of  diagnosis  still  remains  to  be  deter- 
mined. 

In  making  a  diagnosis  the  surgeon  must  in  many  cases  be  guided  by  joroba- 
bilities  only,  as  the  grounds  for  a  positive  assertion  may  not  be  found. 

The  chief  source  of  en-or  lies  in  mistaking  a  simple  pelvic  peritonitis,  or  a 
pyosalpinx,  or  carcinoma  of  the  ovary  with  eifusion,  or  even  an  ovarian  tunioi', 
for  tuberculosis.  In  a  case  in  the  hands  of  Dr.  L.  M.  Sweetnam,  with  amenor- 
rhea followed  by  an  irregular  flow  and  severe  pain,  extra-uterine  pregnancy  was 
diagnosed,  but  the  patient  died  later  of  tuberculosis. 

Again,  a  diagnosis  of  hysteria  or  of  simple  dysmenorrhea  has  been  made 
where  the  affection  was  tubercular. 

I  made  this  mistake  at  the  first  examination  of  a  large,  healthy,  florid  young 
woman  with  many  characteristic  hysterical  traits,  who  complained  of  constant 
pain  in  the  pelvis,  exaggerated  at  each  period.  She  had  general  marked  sensi- 
tiveness on  pressure  over  the  vaginal  vault  and  the  lower  abdomen,  but,  on  ac- 
count of  the  dej)th  of  the  pelvis,  the  examination  was  unsatisfactory  and  noth- 
ing; was  felt.  Fortunatelv,  at  a  later  date  I  made  a  more  thorough  examination 
under  anesthesia  and  found  ovaries  and  tubes  still  movable,  but  restricted  by 
long  adhesions.  An  abdominal  section  showed  that  ovaries  and  tubes  and 
uterus  were  covered  with  tubercles,  and  the  adhesions  were  numerous  and 
only  separable  with  difficulty ;  the  uterus,  ovaries,  and  tubes  had  to  be  re- 
moved. 

A  general  practitioner  will  be  pecuharly  liable  to  commit  this  error  in  simi- 
lar cases,  and  he  can  only  avoid  it  by  insisting  on  an  examination  under  anes- 
thesia, by  a  competent  specialist,  in  all  cases  where  pelvic  pain  is  persistent. 

Tuberculosis  must  be  borne  in  mind  in  all  cases  of  pelvic  inflammatory 
disease  with  masses  posterior  and  lateral  to  the  uterus,  with  marked  tenderness 
on  pressure  in  the  vagina  or  over  the  lower  abdomen  ;  the  probabilities  are  still 
greater  if  encysted  accumulations  can  be  felt  in  the  lower  abdomen,  more  espe- 
cially if  a  large  amount  of  fluid  has  existed  and  been  partially  absorbed. 

I  think  the  tenderness  in  tuberculosis  greater  and  more  persistent  than  in 
simple  inflammation. 

The  history  of  chills  with  fever,  or  the  statement  by  the  patient  that  she  has 
had  "  malaria  "  or  "  dumb  chills,"  must  be  carefully  noted,  together  with  pain 


TUBERCULOSIS.  14:1 

in  walking  and  pain  in  the  back,  and  especially  painful  micturition.  A  phthis- 
ical facies  will  sometimes  strongly  suggest  a  diagnosis. 

One  patient  presented  such  a  suggestive  history  as  this  :  She  was  fii-st  taken 
suddenly  ill  with  high  fever  and  general  pains,  and  a  constant  painful,  dry 
cough,  with  rapid  breathing ;  when  these  symptoms  subsided  the  abdomen  was 
noticed  to  be  swollen,  and  by  palpation  I  found  distinct  masses  and  loculi  of 
fluid  in  the  lower  abdomen.     The  diagnosis  was  confirmed  by  operation. 

A  negress  was  confined  to  bed  two  years  before  with  a  severe  illness  due  to 
a  lung  disease ;  she  had  had  some  cough  ever  since  recovery,  and  caught  cold 
easily.  Four  months  before  I  saw  her  she  had  to  go  to  bed  on  account  of  ab- 
dominal pains  and  swelling,  with  fever.  After  the  removal  of  adherent  tubo- 
ovarian  tubercular  masses  she  recovered  her  health  and  gained  fifty  pounds  in 
weight. 

In  numerous  cases  I  have  noted  an  enlarged  utenis,  as  large  even  as  a  two 
and  a  half  or  three  months'  pregnancy — indeed,  the  possibility  of  j)regnancy 
was  seriously  considered  in  three  cases.  The  position  of  the  uterus  is  variable ; 
it  is,  as  a  rule,  fixed  with  the  appendages  by  adhesions  to  the  pelvic  walls  and 
floor.  The  cervix  was  softened  in  five  of  my  cases.  The  lateral  masses  are 
often  indistinctly  outlined. 

I  mistook  one  case  seen  for  the  first  time  on  the  operating  table  for  a  multi- 
loeular  ovarian  cyst ;  there  was  a  marked  prominence,  with  dullness  of  the  an- 
terior part  of  the  abdomen  due  to  four  liters  of  fluid  ;  on  the  right  side  was  a 
firm  boss  as  big  as  a  cocoanut ;  the  flanks  were  tympanitic.  The  pelvis  was 
filled  with  an  elastic  mass  bulging  down  the  floor  and  pushing  the  cervix  down 
and  to  the  left,  and  the  fundus  could  not  be  felt. 

The  possibility  of  an  encysted  tubercular  peritonitis  simulating  an  ovarian 
cyst  in  this  way  has  been  carefully  considered  by  Dr.  W.  T.  Howard,  of  Balti- 
more {Trans.  Amer.  Gynecol.  Soc,  1885,  p.  41).  Dr.  Howard's  patient  was  a 
negress,  twenty-four  years  old.  The  abdomen  was  enlarged  to  the  size  of  a 
seven  months'  pregnancy,  and  presented  the  appearance  of  an  ovarian  cyst. 
"  The  signs  of  a  simple  unilocular  cyst  seemed  perfectly  developed."  She  was 
suffering  also  from  a  pleurisy. 

The  differential  signs  between  tubercular  peritonitis  and  an  ovarian  cyst  or 
a  uterine  fibro-cyst  must  rest  first  upon  the  history  of  the  rapid  growth  of  the 
effusion,  upon  the  fact  that  the  anterior  part  of  the  abdomen  is  tympanitic  in 
peritonitis  so  long  as  the  amount  of  effusion  is  small,  and  becomes  dull  and  tense 
only  when  it  has  increased  enough  to  lift  the  anterior  wall  well  up  from  the 
mutually  adherent  intestines.  The  presence  of  tympany  m  the  flanks  does  not 
help  to  differentiate  a  cyst  from  an  effusion  in  these  cases,  because  the  fluid  is 
also  encysted  by  the  adhesions.  Coincident  pleurisy  is  a  most  suggestive  sign. 
If  the  fluid  is  removed  by  tapping,  the  al)dominal  wall  collapses  and  irregular 
hard  masses  are  felt  within.  The  most  valuable  means  of  arriving  at  a  differ- 
ential diagnosis  is  by  means  of  a  thorough  bimanual  examination  by  the  rectum 
and  by  the  abdomen,  at  the  same  time  drawing  down  the  cervix  so  as  to  bring 
the  pelvic  organs  within  reach.     A  fibro-cystic  tumor  will  in  this  way  be  differ- 


142  TUBERCULAK    PERITONITIS. 

entiated  from  a  simple  sacculated  collection  by  the  connection  of  the  former 
with  the  uterus,  and  an  ovarian  cyst  will  be  recognized  by  its  pedicle.  Car- 
cinomatous disease  forming  hard  masses  through  the  peritoneum,  resembling 
those  of  tuberculosis,  may  often  be  recognized  by  distinct  nodular  and  papillary 
masses  felt  in  the  pelvis.  And  in  case  of  tuberculosis  the  small  tubercle  knots 
may  sometimes  be  felt  with  perfect  distinctness  through  the  rectal  mucosa. 

The  tubercle  bacilli  are  rarely  found  in  the  ascitic  and  encapsulated  fluids ; 
they  are  found  with  difiiculty  in  sections  of  the  tubercles,  while  they  may  be 
abundant  in  cheesy  foci  and  may  also  be  found  by  crushing  a  tubercle  and  ex- 
amining it  fresh  on  a  cover-glass.  It  is  sometimes  necessary  to  make  a  pains- 
taking search  l)efore  the  characteristic  bacillus  is  found,  but  a  positive  diagnosis 
may  be  made  from  a  single  typical  organism. 

As  pointed  out  by  Dr.  J.  W.  Williams,  a  large  percentage  of  the  adherent 
tubes  and  ovaries  removed  on  account  of  chronic  pelvi-peritonitis  is  in  reality 
tubercular,  but  the  demonstration  can  only  be  made  after  a  most  painstaking 
microscopic  investigation ;  the  diagnosis  can  not  be  made  either  before  or  at 
the  operation. 

Tubercle  bacilli  may  be  discovered  in  a  vaginal  discharge  when  the  uterus  is 
involved,  and,  as  already  stated,  one  of  the  surest  ways  of  making  a  diagnosis  is 
by  means  of  uterine  scrapings,  which  exhibit  tubercular  foci  in  a  large  percent- 
age of  cases  where  the  disease  is  advanced  in  the  tubes.  Sometimes,  too,  there  is 
a  marked  affection  of  the  uterus  where  disease  in  the  tubes  is  still  in  its  early 
stages.  The  peculiarities  of  these  scrapings  have  been  described  in  Chapter 
XIV,  p.  489. 

I  would  briefly  recapitulate  the  important  clinical  diagnostic  points,  and 
they  are  valuable  just  in  proportion  as  a  number  of  them  are  associated  together, 
under  these  eleven  heads  : 

1.  Often  a  sudden  onset  of  the  disease,  it  may  be  after  pregnancy  or  a  mis- 
carriage. 

2.  A  history  of  chills  with  fever,  or  "  malaria,"  but  without  the  Plasmo- 
dium.    Sometimes  the  stage  of  invasion  is  put  down  as  "  typhoid  fever." 

3.  Gradual  increase  of  swelling,  terminating  in  a  marked  enlargement  of  the 
abdomen. 

4.  More  or  less  constant  abdominal  pain  increased  especially  by  walking. 

5.  Pain  in  urinating. 

6.  Pelvic  masses  which  can  not  be  distinctly  outlined  either  by  palpation  or 
percussion ;  there  is  something  puzzling  and  peculiar  about  the  relations  of  the 
masses  to  the  pelvic  organs. 

7.  Apparent  change  in  the  position  of  the  masses  in  the  abdomen  noted  at 
subsequent  examinations. 

8.  Great  tenderness  on  pressure  at  the  vaginal  vault  and  over  the  lower 
abdomen. 

9.  Sometimes  an  enlarged  uterus. 

10.  Evidences  of  an  encysted  peritonitis. 

11.  Emaciation — tubercular  facies. 


TUBERCULOSIS.  143 

12.  Slight  persistent  evening  rise  of  temperature,  often  M'itli  subnormal 
morning  temperature,  lasting  for  weeks  or  months. 

13.  The  discovery  of  tubercle  bacilli  in  vaginal  or  uterine  secretions  or  in 
the  endometrium  after  curettage,  or  more  rarely  in  the  fluid  obtained  by  tapping 
a  cyst  by  the  vagina  or  by  the  abdomen. 

Treatment . — There  can  be  no  doubt  but  that  many  patients  suffering 
from  tubercular  peritonitis  recover  spontaneously,  without  any  assistance  what- 
ever. On  the  other  hand,  a  large  number  become  chronic  invalids,  showing  but 
little  if  any  change  in  their  condition  from  year  to  year ;  others  again  grow  pro- 
gressively worse,  until  the  whole  peritoneum  is  studded  with  tubercles,  and  the 
intestines  become  mutually  adherent,  or  effusion  increases  rapidly  in  quantity, 
greatly  distending  the  abdomen,  becoming  at  times  purulent,  and  the  neglected 
patient  dies  of  exhaustion. 

No  treatment  other  than  general  hygienic  measures  is  called  for  where  the 
patient  has  had  an  attack  of  peritonitis  believed  to  be  tubercular,  and  is  con- 
stantly improving ;  but  such  a  patient  ought  to  be  warned  of  the  possibility  of  a 
recurrence  of  the  attack  and  kept  under  observation.  If  a  tender  pelvic  mass  is 
found  by  vaginal  examination,  and  it  does  not  disappear  in  the  course  of  several 
months,  it  should  be  removed. 

When  a  patient  comes  under  observation  with  pain,  or 
ascites  and  pelvic  masses,  the  only  proper  method  of 
treatment  is  the  removal  of  as  much  of  the  disease  as 
possible   by   an   abdominal    section. 

With  timely  treatment  all  cases  originating  within  the  pelvis  may  be  cured. 
Often  even  advanced  and  seemingly  hopeless  cases,  apparently  in  the  last  stages, 
will  recover  after  operation. 

Only  those  cases  should  be  abandoned  as  hopeless  where  the  patient  seems 
to  be  actually  dying,  or  where  there  is  such  an  extreme  state  of  prostration, 
without  marked  effusion  in  the  abdomen,  that  the  attempt  to  remove  adherent 
pelvic  structures  would  be  manifestly  fatal  within  a  short  time. 

The  curability  of  the  disease  by  operation  is  abundantly  demonstrated  by  my 
own  experience.  None  of  the  twenty-two  cases  cited  above  died  from  the 
operation,  though  one  died  a  month  later  with  numerous  adhesions  about  the 
site  of  some  tuberculous  intestinal  ulcers. 

One  of  those  not  included  in  this  list  operated  on  in  1SS(»  is  now  living 
and  well. 

In  a  case  operated  upon  by  Dr.  W.  S.  Halsted  at  the  Johns  Hopkins  Hos- 
pital, the  capsule  of  the  liver  was  found  studded  w^ith  tuberculous  nodules, 
which  were  also  distributed  over  the  adherent  intestines,  the  diagnosis  being 
coniirmed  by  the  microscope.  The  patient  recovered  and  went  out ;  four 
months  and  a  half  later  she  returned  and  died  in  the  hospital  ward  of  pneu- 
monia. At  the  autopsy  no  adhesions  were  found  between  intestines,  but  a 
number  of  little  withered,  scattered,  pigmented  iibrous  nodules  proved  to  be 
tubercles  containing  in  their  center  numerous  bacilli.     There  were  no  tubercles 

in  the  chest.     Thus  the  abdominal  trouble  had  steadily  retrograded  and  become 
50 


144 


TUBERCULAR   PERITONITIS. 


■cr-'l^i:-- 


innocuous,  and  the  opportunity  to  examine  it  was  due  to  the  accidental  occur- 
rence of  a  pneumonia. 

The  object  of  tlie  operation  is  threefold : 

First,  to   remove,   if  possible,   the   focus   of   the   disease. 
Second,  to   remove   all   fluid   exudate. 
Third,  to   release   dangerous   adhesions. 

The  abdominal  incision  should  not  be  more  than  4  or  5  centimeters  (1^  to  2 
inches)  long  at  first,  and  lengthened  afterward  according  to  necessity. 

In  opening  the  abdomen  an  unusual  vascularity  of  the  walls  is  often  noted, 
and  the  fat  is  frequently  of  a  pale,  unhealthy,  watery  appearance,  like  the  fat 

which  in  the  market  con- 
demns meat  to  an  experi- 
enced buyer,  and  the  pa- 
rietal peritoneum  may  be 
2  to  3  millimeters  thick. 
The  operator  must  in 
all  cases,  where  the  pa- 
tient's condition  is  good 
enough,  remove  either 
one  or  both  tubes  and 
ovaries,  if  they  are  the 
seat  of  tuberculous  dis- 
ease, and  it  is  better  to 
do  this  when  it  is  possi- 
ble, no  matter  how  much 
the  disease  has  extend- 
ed beyond  its  original 
focus.  It  is  better,  too, 
where  the  omentum  is 
extensively  infiltrated 
and  its  utility  as  an  ab- 
sorbent is  lost,  to  remove 
it  close  up  to  the  colon. 
Where  both  sides  are  extensively  involved,  as  shown  in  Fig.  337,  it  will  be 
better  to  remove  the  uterus  too,  on  account  of  the  probable  involvement  of  the 
uterine  mucosa. 

If  the  uterus  is  so  buried  that  its  enucleation  presents  unusual  difficulties,  the 
tubes  and  ovaries  may  be  removed  separately,  as  shown  in  Fig.  338. 

If  the  ovary  is  simply  involved  in  adhesions  and  the  disease  seems  to  be 
almost  confined  to  the  tube,  this  should  be  removed  and  the  ovary  left.  This 
condition  is  sometimes  found  in  tlie  form  of  a  nodular  salj)ingitis. 

Much  care  must  be  exercised  in  the  enucleation  on  ac- 
count of  the  rigid  friable  nature  of  the  structures,  which 
tear  widely  if  injudiciously  pulled.  In  one  of  my  cases  the  ovary 
and  tube  of  the  left  side  felt  like  a  mass  of  bone.    The  difficulties  will  be  greatly 


Fig.   338. — Tuberculosis   of   the    Tube,   Posterior    Surface    of  the 
Left  Ovary  and  Tube. 

Note  the  thickening  of  the  tube  and  tlie  disappearance  of  the  meso- 
salpinx. The  fimbriie  have  all  disappeared,  except  a  few  little  blunt 
budlike  proces.ses.     Path.  No.  Ibi.     Natural  size. 


^=^.§.2  1 


aEjH^f? 


TUBERCULOSIS.  145 

lessened  by  a  slow,  painstaking  enucleation,  seeking  out  the  points  of  vantage 
generally  found  beneath  the  ovary  on  the  pelvic  floor,  and  lifting  the  ovary  and 
tube  up  and  tying  off  the  pedicle  at  both  ends  to  include  uterine  and  ovarian 
vessels. 

One  serious  difficulty  is  that,  owing  to  the  rigidity  of 
the  broad  ligaments,  the  pedicle  can  not  be  brought  up 
into  the  incision  and  must  be  treated  down  in  the  pelvis. 
I  tore  the  rectum  in  separating  dense  adhesions  in  one  case,  and  was  obliged  to 
suture  it.  In  another  case  adherent  small  intestines  were  separated  by  leaving 
some  of  the  inflammatory  mass  on  the  bowel.  Sutures  were  also  needed  to 
repair  several  rents  in  the  bowel. 

The  details  of  the  operation  of  salpingo-oophorectomy  are  given  in  Chapter 
XXYI. 

Where  the  pelvic  structures  can  not  be  removed,  the 
operator  must  content  himself  with  fulfilling  the  two  re- 
maining indications,  which  must  in  any  event  always  be 
attended  to  — ^that  is,  the  removal  of  all  fluid  and  the  re- 
liefofthecom  plications. 

The  fluid  of  a  tubercular  peritonitis  is  sometimes  almost  syrupy  in  consist- 
ence, and  I  have  repeatedly  noticed  its  coagulation  as  soon  as  it  is  exposed  to 
the  air ;  at  other  times  it  is  opalescent,  brown,  and  full  of  flakes  of  lymph,  or 
punileut.  The  spontaneous  coagulability  of  the  fluid  resembles  that  sometimes 
seen  in  fibro-cystic  tumors  and  considered  pathognomonic  of  this  affection  by 
Dr.  W.  L.  Atlee  and  others.  Several  writers  have  noted  this  error.  Dr.  Wil- 
liam T.  Howard  among  others. 

All  the  serous  and  bloody  fluid  contained  in  the  abdomen  must  be  thoroughly 
sponged  out  after  dropping  the  table  to  a  level,  so  as  to  cause  the  fluid  in  the 
upper  abdomen  to  gravitate  toward  the  pelvis.  Several  liters  may  be  evacuated 
in  this  way  before  the  peritoneum  is  dry. 

Purulent  collections  are  usually  sacculated,  and  not  infrequently  in  the  mid- 
dle or  upper  part  of  the  abdomen  behind  the  anterior  wall. 

In  evacuating  such  an  abscess  care  must  be  exercised  not  to  open  an  avenue 
into  the  general  abdominal  cavity.  Mutiple  abscesses  among  the  intestines  are 
apt  to  be  associated  with  intestinal  tuberculosis,  and  unless  easily  reached  without 
injury  to  the  bowel,  would  best  be  let  alone. 

Adhesionsmust  be  separated  when  a  single  loop  of  in- 
testine is  found  attached  to  the  abdominal  wall  or  pinned 
down  in  the  pelvis,  but  the  general  adhesions  uniting  all 
the  small  intestines  into  one  big  saclike  mass  ought  not 
to  be  touched,  for,  as  is  evident  from  the  patient's  history,  the  peristaltic 
function  of  the  bowels  is  not  interfered  with  by  the  general  obliteration  of  the 
peritoneum  where  the  normal  mutual  relations  are  preserved.  Paradoxical  as  it 
may  seem,  a  single  adhesion  of  a  kimckle  of  the  small  bowel  or  colon  holding  it 
down  in  some  abnormal  position,  as  to  the  pelvis  or  abdominal  wall,  is  far  more 
dangerous. 


146 


TUBERCULAR    PERITOXITIS. 


A  piece  of  the  thickened  parietal  peritoneum,  or  of  an  affected  omentum, 
should  be  removed  for  microscopic  examination,  when  the  ovaries  and  tubes  are 
not  taken  out ;  one  of  the  most  satisfactory  ways  also  of  demonstrating  the  na- 


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i'lG.    339. — DiAGRAil    SHOWING    THE    EelATIVE    ADVANTAGES   OF    CLOSING    OR    OF   DRAINING    THE    AbDOMEN   IN 

THE  Treatment  of  a  Tubercular  Peritonitis. 

Beginning  with  the  day  of  operation  the  temperature  dropped  to  normal,  and  recovery  ensued  in  the 
■dramed  cases  by  the  ninth  week  ;  in  those  which  were  not  drained  the  temperature  became  normal  and  the 
convalescence  well  established  before  the  second  week. 

ture  of  the  disease  is  by  inoculating  the  peritoneum  of  a  guinea-pig,  which  will 
develop  tuberculosis  and  die  within  the  course  of  two  or  three  months.  The 
nodular  tubercular  masses  may  be  crushed  and  examined  under  the  microscope 


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IN  THE  Cases  of  Tubercular  Peritonitis  which  were  not  Drained. 


TUBERCULOSIS. 


147 


during  the  operation  to  relieve  any  doubt  existing  as  to  the  diagnosis  between 
tuberculosis  and  peritoneal  carcinoma. 

Drainage . — After  completing  the  operation  the  abdomen  should  be  closed 
without  drainage,  unless  this  is  made  necessary  by  some  complication,  such  as 
the  23i"esence  of  pus,  which  can  not  be  completely  removed,  or  such  an  injury  to 
the  bowel  as  can  not  be  satisfactorily  repaired  and  may  give  rise  to  a  septic  peri- 
tonitis. 

It  has  long  been  the  fashion  to  attribute  the  good  results  of  operation  in 
tubercular  peritonitis  to  drainage.  I  have  abandoned  all  drainage  in  these  cases 
for  more  than  live  years. 

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Fig.  341. — Chabt  sho'wing  Eeoovery  after  Kemoval  of  both  Uterine  Tcbes  and  Ovaries  in  a  Case 
OF  Tubercular  Salpingitis  and  Peri-oophoritis  and  Tubercular  Peritonitis. 

No  drainage  was  used,  and  the  continuous  line  shows  the  speedy  defervescence  within  a  week  after  the 
operation.    K.  J.,  Feb.  17, 1894.     Gyn.  No.  2597. 

Serious  objections  to  drainage  are  that  the  track  of  the  drain  is  liable  to 
remain  open  indefinitely,  much  to  the  annoyance  of  the  patient ;  a  drain  also 
renders  the  patient  liable  to  hernia. 

The  following  facts,  however,  are  sufficient  in  themselves  to  settle  this  impor- 
tant question  in  favor  of  closing  the  incision  completely.  The  cases  referred  to 
as  drained  are  those  in  which  the  drain  was  inserted  with  a  view  of  curing  the 
disease,  and  not  of  providing  for  the  eompHcations  above  noted. 

The  average  duration  of  convalescence  in  six  cases  up  to  complete  remission 
of  the  fever  with  drainage  was  59  days.  The  average  period  of  convalescence 
without  drainage  was  17"3  days. 

The  longest  duration  of  fever  in  a  drained  case  was  71  days,  and  the  shortest 
was  10  days.  The  longest  continuance  of  the  fever  in  a  case  which  was  not 
drained  was  54  days,  and  the  shortest  2  days. 


148  TUBERCULAR    PERITONITIS. 

This  matter  is  so  important  that  I  present  it  here  in  a  diagram,  which  shows 
the  extraordinary  difference  in  tlie  two  groups  of  cases,  in  the  rapidity  of  the 
drop  from  the  average  temperature  at  the  time  of  operation  down  to  the 
base  line  of  normal  temperature. 

The  angle  between  each  of  these  lines  and  the  perpendicular  might  also 
well  be  taken  as  the  measure  of  the  diiierence  in  advantage  in  the  two  meth- 
ods ;  the  smaller  the  angle  the  quicker  the  drop  to  the  normal,  and  therefore 
the  greater  the  advantage  of  the  plan. 

I  present  here,  also,  a  composite  chart  of  all  the  cases  which  were  not  drained. 
It  is  constructed  by  adding  up,  in  separate  columns,  the  morning  and  evening 
temperatures  of  the  group  of  cases  under  consideration,  and  dividing  the  sum  in 
each  column  by  the  number  of  cases.  For  example,  the  composite  temperature 
of  the  first  evening,  on  the  day  of  operation,  in  twelve  cases,  is  the  sum  of  all 
the  temperatures  for  that  evening  divided  by  twelve,  and  so  on  for  each  morning 
and  evening  thereafter.  We  can  do  this  with  a  degree  of  precision  in  surgical 
cases  which  vrill  not  be  quite  attainable  in  medical  cases,  because  the  operation 
gives  a  definite  starting  point.  The  great  advantage  of  this  method  of  investi- 
gating the  temperature  and  pulse  record  is  that  it  obliterates  all  individual 
peculiarities  and  reveals  the  average  or  the  true  type. 

In  comparison  with  this  I  present  the  chart  of  a  case  (K.  J.,  2597,  Feb.  21, 
1894),  closely  approximating  the  normal  in  its  defervescence,  but  still  showing 
individual  peculiarities. 

In  the  drained  cases  the  temperature  curve  showed  marked  daily  variations, 
more  like  those  of  a  septic  fever. 

In  the  cases  closed  without  drainage  there  was  a  gradual  but  regular  drop 
down  to  the  normal. 


CHAPTER   XXI Y. 

SUSPENSION   OF   THE   UTERUS. 

1.  Historical  review. 

2.  Simpler  methods  of  treating  retroflexion :  1.  Manual  reduction.     2.  Pessaries.     3.  Resection  of 

lax  outlet. 

3.  Indications  for  suspension. 

4.  Methods  of  operation. 

5.  Answer  to  objections  to  this  method. 

6.  Operation :  1.  First  step,  the  incision.     2.  Second  step,  introduction  of  index  and  middle  fin- 

gers to  elevate  the  fundus.     3.  Third  step,  attachment  of  uterus  to  anterior  abdominal  wall. 

7.  Final  results. 

Historical  Review. — Suspension  of  the  uterus,  ventrofixation, 
hysterorrhaphy,  and  hysteropexy  are  synonymous  terras  applied  to 
a  number  of  similar  abdominal  operations,  all  of  which  are  employed  with  a 
view  of  permanently  overcoming  retrode\aation8  (retroflexions  and  retrover- 
sions) of  the  uterus  by  the  formation  of  an  artificial  ligament  or  ligaments  hold- 
ing the  fundus  in  an  anterior  position. 

I  first  called  attention  to  this  mode  of  relieving  retroflexion  in  Germany  in 
the  spring  and  summer  of  1886,  when  I  also  secured  notes  of  unpublished  cases 
similarly  treated  by  Dr.  Brennecke  of  Magdeburg,  Prof.  TVerth  of  Kiel,  and 
Prof.  Sanger  of  Leipsic,  which  were  published  with  an  original  case  of  my  own. 
Prof.  Olshausen,  of  Berlin,  who  had  the  subject  under  consideration  at  the  same 
time,  was  the  first  to  publish  a  paper  upon  it,  Oct.  23,  1886,  entitled  Ueber 
ventrale  Operationen  hei  Prolapsus  unci  Retroversio  Uteri  {Centr.  f.  Gyn., 
No.  43,  1886),  My  own  paper,  entitled  Ilysterarrhaphy  and  describing  a 
case  operated  upon  April  25,  1885,  was  read  before  the  Philadelphia  Obstet- 
rical Society,  l^ov.  4,  1886,  and  j'ublished  in  the  Ainer.  Jour,  of  Ohst.y 
Jan.,  1887. 

Since  these  publications  the  correction  of  retroflexions  of  the  uterus  by  an 
abdominal  operation  has  been  widely  and  fully  tested,  and  has  undergone  in 
different  hands  a  series  of  modifications  more  or  less  useful. 

Simpler  Methods  of  treating  Retroflexion. — S  u s p e  n  s i  o n  of  the  uterus 
should  be  resorted  to  only  in  cases  of  persistent  retro- 
flexion which  refuse  to  yield  to  simpler  plans  of  treat- 
ment through  the  vagina,  and  then  only  when  the  dis- 
comforts of  the  retroflexion  are  sufficient  to  interfere 
seriously   with   health. 

In  many  cases  the  physician  will  be  justified  in  extending  his  treatment  over 
some  months  in  the  endeavor  to  bring  the  uterus  into  anteposition  and  keep  it 

149 


150 


SUSPENSIOX    OF   THE    UTERUS. 


there.     One  or  more  of  the  three  following  plans  of  treatment  are  serviceable 
to  this  end : 

1.  Manual  reduction. 

2.  Packs  and  pessaries. 

3.  Resection  of  a  lax  outlet. 

For  manual  reduction    the  vagina  should  be  cleansed  and  the  anterior 
lip  of  the  cervix  caught  by  a  corrugated  tenaculum  or  tenaculum  forceps  (Fig. 


Yio.  342. — Suspension  of  the   Dtekus,  seen  from  Above  ;    from  a  Case  opened  over  Six    Months 

AFTER    THE     SUSPENSORY    OPERATION. 

Notice  the  long  fibrous  bands  uniting  the  posterior  surface  of  the  uterus  to  the  anterior  abdominal  wall. 
Jan.  6,  1896. 


225)  and  drawn  down  toward  the  vaginal  outlet  (Fig.  226) ;  while  it  is  held  in 
this  position  the  index  linger  is  introduced  into  the  rectum,  and  used  to  raise 
the  fundus  up  into  the  pelvis,  reducing  the  angle  of  flexion  (Fig.  229).  There 
is  sometimes  a  sensible  jump  as  the  body  of  the  uterus  escapes  from  between 
the  utero-sacral  folds  wdiere  it  had  lain  incarcerated,  often  giving  the  false  im- 
pression that  there  is  a  retroflexion  with  adhesions.  As  soon  as  the  fundus  is 
elevated  in  this  way  the  cervix  is  carried  back  into  the  sacral  hollow  by  means 


SIMPLER    METHODS    OF   TREATIXG    RETROFLEXION. 


151 


of  tlie  forceps,  tlius  rotating  the  uterine  body  forward  (Fig.  227).  The  rest  of 
the  reduction  is  now  effected  bimanually  through  the  vagina  and  the  abdominal 
walls.  The  fundus  is  caught  with  the  abdominal  hand  pressing  deep  down  into 
the  pelvis,  drawn  forward  and  held  there,  while  the  vaginal  finger  indents  the 


Fig.  343. — Steps   in   the   Eeduction  of  the   L"teru.s  in  the  Palli.itive  Treatment  of  "Retroflexion. 
The  auterior  lip  of  the  cervix  is  grasped  with  a  tenaculum  forceps  aiid  drawn  in  the  direction  of  the  aiTOW. 

uterus  on  its  anterior  surface  at  the  junction  of  the  cervix  and  body,  and  so  brings 
it  into  complete  anteflexion  (Fig.  228).  By  further  pushing  the  cervix  higli  up 
toward  the  promontory  of  the  sacrum  and  the  fundus  down  behind  the  symphy- 
sis, the  anterior  position  is 
exaggerated  (Fig.  230). 

A  Hodge,  or  a  Thomas, 
or  a  Munde  pessary  will  in 
some  cases  so  far  alleviate 
the  symptoms  of  a  retro- 
flexion, even  though  the 
flexion  is  not  cured,  as  to 
obviate  the  necessity  for 
an  operation. 

Wool  and  boroglycer- 
ide  cotton  packs,  used  for 
a  time,  will  also  often  tide 
the  patient  over  a  period 
of  discomfort  without  op- 
eration. 


Fig.  344.- 


-The  traction  straightens  out  the  angle  of  tle.vion  and  bringa 
the  body  of  the  uterus  within  easy  reach. 


A  m  a  r  k  e d  relaxation  of  the  vaginal  outlet  is  often  as. 
s  o  c  i  a  t  e  d  with  retroflexion  where  the  flexion  has  followed  ]xirtnriti(»n  ; 
in  such  patients  the  discomforts  often  arise  from  the  tugging  upon  the  broad 
ligaments  of  a  uterus  working  its  way  down  to  the  outlet,  and  the  simple  flexion 
is  not  the  cause  of  the  })ain.     In  a  considerable  number  of  these  cases  an  oper- 


153 


SUSPENSION    OF   THE    UTERUS. 


ation  restoring  the  lax  outlet  relieves  both  the  discomforts  and  the  tendency 
to  prolapse,  although  the  flexion  persists.  When  the  patient  is  not  relieved  by 
this,  an  abdominal  operation  to  correct  the  flexion  may  be  resorted  to  later. 


Fig.  345. — The  finger  is  then  introduced  into  the  rectum,  and  by  pushing  in  the  direction  of  the  arrow 

slight  anteflexion  is  produced. 


Indications  for  Operation; — Suspension  of  the  utenis  is  not  indicated  in  all 
cases  of  persistent  retroflexion. 

The  commonest   group   of   symptoms  calling  for   the  sus- 
pension are  a  sense  of  weight,  discomfort,  or  bearing  down,  aggravated  by 

exertion,  inability  to  walk  with- 
out pain,  backache,  and  pain  in 
the  lower  abdomen  and  thighs. 
These  symptoms  are  usually 
worse  at  the  menstrual  period, 
when  the  pelvic  discomforts  may 
be  so  great  as  to  put  the  patient 
to  bed  for  several  days.  As  a 
rule,  women  suffering  from  re- 
troflexion are  intensely  nervoiis, 
liable  to  dyspepsia,  palpitation, 
neuralgias,  and  headaches.  The 
case  is  still  clearer  if  all  the  symp- 
toms are  relieved  by  rest.  Back- 
ache is  the  most  fallible  symptom, 
and  the  surgeon  must  be  cautious 
about  promising  its  relief.  Only 
rarely  is  the  renal  function  inter- 
fered with  by  pressure  on  the  ureters,  giving  rise  to  attacks  of  renal  colic.  Occa- 
sionally the  pressure  of  the  retroflexed  fundus  upon  the  rectum,  causing  obstinate 
constipation  and  great  pain  in  defecation,  is  the  chief  indication  for  operation. 


Fig.  340. — The  forceps  are  then  used  to  carry  the  cervi.\ 
well  back  into  the  pelvis. 


IXDICATIOXS   FOR    OPERATIOX. 


153 


A  good  way  to  test  the  probable  effect  of  an  operation 
for  retroflexion  is  bj  lifting  the  uterus  and  supporting  it  on  a  wool  pack  or  a 
pessary ;  if  this  affords  decided  relief  after  a  fair  trial,  the  flexion  may  be  con- 
sidered to  be  the  source  of  the  disturbance.  Suspension  should  always  be  used 
in  those  cases  which  Dr.  B.  Mc]Monagle  has  described  as  '•'■  tied  to  the  physician's 
oflice  by  their  ailment,"  now  better  and  now  worse,  and  so  continuing  indefi- 
nitely under  treatment. 

A  r  e  t  r  o  f  1  e  X  6  d  adherent  uterus  is,  as  a  rule,  the  result  of  a  pelvic 
peritonitis  primarily  involving  the  tubes  and  ovaries,  and  a  suspensory  operation 

after  freeing  these  adhesions  is  not  advisable  if  they 
are  very  extensive.  It  only  exposes  a  raw  surface 
to  the  formation  of  intestinal  adhesions,  and  if  the 
tubes  and  ovaries  are  so  diseased  as  to  be  practically 
useless,  there  is  no  advantage  in  keeping  the  dis- 


Fio.  .347. — The  flexion  being  in  this  manner  rcdaoed.  the  fundus  is  within  reach  of  the  hand  palpating 
through  the  abdominal  wall,  grasping  it  and  forcing  it  in  the  direction  of  the  arrow ;  a  finger  in  the 
vagina  at  the  same  time  pushes  the  cervix  baclc  into  the  sacral  hollow. 

eased  womb.  I  have,  however,  in  many  cases  of  general  light  pelvic  adhesions, 
freed  uterus  and  ovaries  and  then  raised  the  uterus  and  attached  it  to  the  ab- 
dominal wall.  In  one  case  (E.  B.,  2701,  April  6,  1894)  I  found  the  uterus  alone 
adherent  and  both  tubes  and  ovaries  free  ;  the  adhesions  were  easily  severed  and 
the  uterus  suspended. 

In  prolapse  of  the  uterus,  as  I  have  pointed  out  in  Chapter  XV, 
the  operations  on  the  cervnx  and  vaginal  outlet  are  generally  sufficient  to  hold 
the  uterus  within  the  pelvis.  But  when  the  vaginal  floor  is  so  weak  and  the 
vault  so  relaxed  that  there  is  doubt  as  to  the  sufficiency  of  the  inferior  sup- 
ports to  retain  the  uterus  unaided,  the  abdomen  may  be  opened  and  the  uterus 
attached  to  the  anterior  abdominal  wall  by  its  posterior  surface,  with  great  me- 
chanical advantage  and  a  greater  assurance  of  success. 


154 


SUSPEXSIOiSr    OF   THE   UTERUS. 


Occupation  has  mucli  to  do  in  deciding  upon  an  operation.  Women 
whose  occupations  require  them  to  be  more  or  less  constantly  on  their  feet  and 
lifting,  suffer  more  from  a  displacement  of  the  uterus  than  others  whose  life 

is  less  laborious.  On 
the  other  hand,  high- 
strung  neurotic  wom- 
en will  suffer  in  the 
same  way,  while  a 
phlegmatic  disposition 
will  experience  no  dis- 
comfort, I  recall  in 
this  connection  an  ex- 
tremely neurasthenic 
hysterical  woman  who 
had  spent  four  years 
on  her  back  in  a 
hydropathic  establish- 
ment and  recovered 
perfect  health  after 
operation.  I  once  op- 
erated, unwittingly, 
on  an  epileptic  patient 
in  the  first  month  of 
her  pregnancy,  and, 
in  spite  of  the  fact 
that  she  had  from  six 
to  eight  attacks  daily, 
she  went  to  term.  Dr.  H.  D.  Fry,  of  Washington,  operated  upon  a  woman,  ten 
weeks  pregnant,  with  an  adherent  retroflexed  incarcerated  uterus ;  after  freeing 
and  suspending  it  to  the  anterior  abdominal  wall,  she  went  to  term. 

Methods  of  Operation. — The  method  at  first  adopted  of  suspending  the  uterus 
by  the  fundus  or  by  bringing  up  its  anterior  face  against  the  abdominal  wall  I 
rejected  over  six  years  ago,  on  account  of  the  mechanical  disadvantage  in  which 
it  left  the  uterus  to  resist  subsequent  retrodisplacement ;  for  a  uterus  lifted 
in  this  way  hangs  with  its  whole  weight  upon  its  attachments,  and  the  perma- 
nent correction  of  the  displacement  must  depend  u^Jon  the  strength  of  the 
adhesions  binding  it  to  the  anterior  abdominal  wall. 

AVhen,  however,  the  body  is  brought  into  a  decided  anteflexion  and  attached 
to  the  abdominal  wall  by  its  posterior  surface,  it  then  lies  in  a  natural  position, 
and  the  forces  of  the  intra-abdominal  pressure  are  no  longer  exercised  in  adding 
to  its  weight  and  tearing  it  loose  from  its  moorings  ;  on  the  contrary,  the  pres- 
sure then  simply  tends  to  lengthen  out  the  adhesions  and 
to  increase  the  anteflexion,  rendering  a  recurrence  of  the  retrodis- 
placement less  likely. 

My  present  operation,  therefore,  as  carried  out  in  over  three  hundred  cases. 


Fig.  348.— The  final  step  is  the  production  of  an  extreme  anteposition  of  the 
fundus,  and  the  insertion  of  a  pacli  into  the  upper  part  of  the  vagina  to 
hold  the  cervix  up. 


3IETH0DS    OF    OPERATIOIvr. 


155 


consists  in  the  following  steps :  An  abdominal  incision  just  over  the  symphysis^ 
the  introduction  of  two  fingers  and  elevation  of  the  retroflexed  fundus,  bring- 
ing it  into  anteflexion,  and  its  retention  there  by  means  of  sutures  through  its 
posterior  surface,  lifting  it  up  to  the  abdominal  wall. 

Answer  to  Objections  to  this  Method . — Three  objections  may 
be  raised  against  the  suspension  of  the  uterus  in  this  way  to  the  anterior  abdomi- 
nal wall : 

First,  that  such  an  operation,  substitutes  a  fixed,  unnatural  anteflexion  for 
a  retroflexion,  and  the  suspensory  operation  is  therefore  not  what  it  purports  to  be 
— a  simple  correction  of  the  retroflexion  with  a  restoration  of  the  normal  condition. 

Second,  that  an  attachment  of  the  body  of  the  uterus  to  the  abdominal 
wall  behind  the  symphysis  pubis,  and  resting  upon  the  bladder,  must  inter- 
fere with  the  natural  disten- 
tion of  this  organ  and  so  ex- 
cite dysuria. 

Third,  that  in  the  event 
of  pregnancy  occurring  after 
suspension  the  patient's  life 
might  be  imperiled  by  the 
inability  of  the  uterus  to 
develop  normally. 

An  experience  of  six 
years  has  brought  a  satis- 
factory   answer    to    each 
these  queries  in  favor  of  the 
operation. 

In  the  first  place,  the 
actual  fixation  to  the  abdom- 
inal wall  lasts  but  a  shor 
time ;  a  few  weeks  after  the 
operation  the  uterus  will  be 
found,  by  a  bimanual  exami- 
nation, lying  with  the  fundus 
behind  the  symphysis  and  in 
a  position  of  easy  anteflexion 
at  a  distance  from  the  anteri- 
or abdominal  wall,  apparently 
normal  in  every  respect  and 
in    no  way   hindered    in    its 

movements  until  the  attempt  is  made  to  throw  it  into  retroflexion  ;  it  will  then 
be  found  limited  in  its  movements  in  this  direction  by  long  adhesions  between 
the  fundus  and  the  abdominal  wall. 

In  four  cases  where  I  have  had  occasion  to  open  the  abdomen  at  periods 
varying  from  one  to  three  years  after  a  suspensory  operation  the  uterus  was 
discovered  each  time  lying  in  easy  anteflexion  with  its  posterior  surface  3  to  5 


Fig.  34y. — Suspension   of  the  Uterus  within  a  Yeau  after 

THE    OpEKATION. 

Showiug  tlie  long  tibrous  band  connecting  the  fundus  of  the 
uterus  with  the  anterior  abdominal  wall.  Tliis  is  continued 
down  in  the  form  of  a  thin  septum  over  the  bladder  and  ante- 
rior face  of  the  uterus.     May  27, 1S90. 


156 


SUSPEXSIOX    OF   THE    UTERUS. 


centimeters  (1^  to  2  inches)  distant  from  the  anterior  abdominal  wall,  with  which 
it  was  connected  bj  a  dense,  smooth,  fibrous  band  from  a  few  millimeters  to  1^ 
centimeter  in  breadth.  In  two  cases  there  were  two  separate  slender  bands. 
In  one  case  these  suspensory  cords  were  thicker  at  the  ends  and  thinned  out  in 
the  middle,  and  the  suspensoiy  sutures  remained  imljedded  in  the  abdominal  end  ; 
in  another  case  (Fig.  350)  one  suture  lav  at  the  abdominal  wall  and  the  other  re- 
mained attached  to  the  uterus.  There  was  no  tension  on  these  lax  bands,  and  it 
was  e\adent  from  the  relationship  that  the  fundus  of  the  uterus  gradually  sinks 


Fig.  350. — Suspex.sion  o*-  the  Lterls  Sseex  a  Year  after  the  Original  Operation. 

Showing  the  long  fibrous  bands  attaching  the  fundus  to  the  anterior  aVjdominal  wall.  One  of  the 
suspensory  sutures  lias  remained  on  the  fundus,  while  the  other  is  seen  on  the  abdominal  wall.  March  2, 
1896.     % 'natural  size. 


after  the  operation,  drawing  out  the  fibrous  tissue  connecting  it  to  the  anterior 
abdominal  wall,  until  the  womb  comes  to  lie,  without  any  tugging,  in  a  natural, 
easy  posture. 

Secondly,  transient  irritability  of  the  bladder  is  occasionally  observed,  as  after 
all  sorts  of  abdominal  operations,  but  it  is  not  frequent  or  persistent  or  in  any 
way  peculiar  to  this  operation.  The  fact  is,  that  the  female  bladder  expands 
physiologically,  like  saddle-bags,  most  from  side  to  side,  and  least  in  an  antero- 
posterior direction,  and  this  method  of  distention  becomes  more  marked  in 
pregnancy.     In  answer  to  this  objection  it  is  also  only  necessary  to  recall  the 


METHODS    OF    OPERATIOX.  157 

frequency  with  wliicli  the  myomatous  uterus  was  treated  a  few  years  ago  by 
pinning  the  stump  in  the  lower  angle  of  the  incision,  and  yet  no  untoward 
bladder  symptoms  were  obseryed. 

Thirdly,  a  critical  study  of  the  effects  of  ventrofixation  and  of  suspension  of 
the  uterus  on  a  subsequent  pregnancy  has  been  made  by  Dr.  C.  P.  Xoble,  of 
Philadelphia  {Trans,  of  the  Amer.  Gyn.  Soc,  1896).  Dr.  Koble  has  found  that 
all  the  serious  difficulties  have  been  met  with  in  the 
cases  having  broad  adhesions  between  the  uterus  and  the 
abdominal  wall;  but  he  did  not  find  it  possible  in  the  collation  of  his  sta- 
tistics to  distinguish  between  the  results  of  the  various  methods  of  operating. 

I  have  heard  from  forty -nine  married  women  upon  whom  I  have  performed 
my  suspensory  operation  at  a  date  sufficiently  remote  to  form  a  judgment  as  to 
the  result ;  they  reported  fourteen  cases  of  pregnancy,  and  in  only  one  of  these 
was  there  any  complication  attributable  to  the  suspensory  operation ;  that  was 
one  of  my  first  Baltimore  cases,  operated  ujjon  Oct.  19,  1889,  when  the  uterus 
was  not  suspended  by  the  fundus  but  by  the  ovarian  ligaments,  and  the  con- 
valescence was  delayed  by  an  infection  of  the  wound  and  discharge  of  the 
ligatures  which  bound  the  uterus  firmly  to  the  abdominal  wall  by  broad  dense 
adhesions.  The  patient  became  pregnant  and  fell  into  labor  Jan.  16,  1891, 
under  the  care  of  Dr.  Helena  Goodwin,  of  Philadelphia  (see  Amer.  Jour. 
Ohs.,  1894,  p.  370).  Her  labor  began  with  a  copious  discliarge  of  amnion 
stained  with  meconium.  The  breech  presented,  and  the  uterine  contractions 
were  regular  and  frequent.  The  ceryix  dilated  with  mechanical  aid.  She 
complained  bitterly  of  pain  in  the  left  side  and  in  the  abdominal  incision. 
The  child,  a  large,  well-formed  male,  was  delivered  instrumentally,  and  died 
of  asphyxia ;  the  placenta  came  away  normally,  and  a  slight  perineal  tear  was 
repaired.  The  afterpains  were  severe  and  long-continued,  associated  with  ex- 
treme tenderness  over  the  uterus  and  in  the  left  side.  Puerperal  fever  set 
in  on  the  third  day  with  a  chill,  and  on  May  7th  the  abdomen  was  opened, 
when  the  uterus  was  found  firmly  fixed  to  the  anterior  abdominal  wall.  There 
was  a  large  mass  of  "  exudate "  on  the  left  side,  which  explained  the  fever. 
The  patient  recovered. 

The  methods  of  suspending  the  uterus  generally  in  vogue  produce  wide- 
spread dense  attachments  of  the  fundus  to  the  abdominal  wall  (fixation  and  not 
suspension),  and  are  productive  of  the  following  serious  difficulties  in  pregnancy 
and  in  labor : 

Difficulties  during  Pregnancy . — (a)  Marked  retraction  of  the 
scar  due  to  the  tugging  adherent  uterus. 

(b)  Constant  pain  in  the  hypogastrium. 

(c)  As  pregnancy  advances  the  cervix  retracts  into  the  pelvis  and  may  even 
become  displaced  posteriorly  up  into  the  abdominal  cavity. 

(d)  The  anterior  portion  of  the  uterine  body  fails  to  expand  and  forms  a 
large,  fleshy,  tumorous  mass,  obstructing  tlie  superior  strait. 

(e)  On  the  other  hand,  the  posterior  part  of  the  uterus  may  become  as  thin 
as  tissue  paper. 

51 


158  SUSPENSION    OF   THE    UTERUS. 

(f)  Abortion  or  premature  labor  may  come  on  spontaneously. 

(g)  Persistent  excessive  nausea  may  be  due  to  traction  on  the  scar  (case  of 
Dr.  Cameron,  of  Montreal). 

Difficulties  during  Labor. — (a)  Labor  may  be  delayed  some 
weeks  beyond  term. 

(b)  The  labor  may  be  powerless,  owing  to  the  inability  of  the  thinned-out 
posterior  uterine  segment  to  expel  the  fetus. 

(c)  The  labor  may  be  obstructed  by  the  mass  of  tissue  in  the  anterior 
uterine  wall,  as  by  a  tumor. 

(d)  The  proper  expansion  of  the  cervix  is  hindered  by  its  abnormal  position 
high  up,  even  in  the  abdomen. 

(e)  Malpositions,  particularly  the  transverse  and  the  breech,  are  more  fre- 
quent than  the  normal  position. 

(f)  The  uterus  in  labor  may  tear  loose  from  its  moorings  with  the  formation 
of  a  large  hematoma  at  the  point  of  rupture. 

In  order  to  relieve  these  complications,  a  variety  of  obstetric  operations  have 
been  found  necessary,  such  as  turning,  the  use  of  the  forceps  high  up,  crani- 
otomy, and  celiotomy  and  amputation  of  the  pregnant  uterus. 

The  most  important  practical  suggestion,  made  by  Dr.  Noble,  is  to  induce 
labor  at  the  eighth  month  if  the  cervix  begins  to  pull  up  out  of  the  pelvis. 

1  am  able  to  answer  the  important  question  as  to  the  behavior  of  the  arti- 
ficial ligaments  during  pregnancy  and  labor  by  the  following  observation : 
J.  A.  H.,  San.  332,  was  operated  upon  for  retroflexion  June  26,  1892.  She 
became  pregnant  and  at  the  calculated  time.  May  30,  1896,  labor  pains  set  in, 
and  she  gave  birth  spontaneously  to  a  male  child  weighing  9^  pounds,  after  nine 
hours  of  normal  labor.  The  only  noticeable  peculiarity  of  the  labor  was  a  right 
obliquity  of  the  uterus  and  an  unusual  prominence  of  the  abdominal  wall. 

After  the  labor  was  over  I  could  distinctly  feel  the  suspensory  band  by 
pushing  the  finger  in  through  the  umbilical  ring  and  at  the  same  time  pulling 
out  the  scar  in  the  lax  abdominal  wall ;  the  long,  tense  suspensory  could  be  traced 
in  this  way  from  the^  anterior  abdominal  wall  below,  over  the  top  of  the  uterus, 
to  its  posterior  face,  where  it  was  attached  a  little  to  the  left. 

Operation. — The  bladder  is  emptied  by  catheter,  and  the  customary  jjrepa- 
rations  made  for  opening  the  abdomen,  after  which  the  pelvis  is  slightly  elevated. 

The  first  step  is  the  making  of  an  incision  4  to  5  centimeters  (If  to  2 
inches)  in  length  through  the  abdominal  wall  in  the  median  line,  ending  at  a 
point  within  2  centimeters  of  the  symphysis. 

The  peritoneum  is  opened  the  full  length  of  the  skin  incision,  and  caught 
with  artery  forceps  in  the  middle  on  both  sides,  drawn  out,  and  the  forceps  laid 
on  the  abdomen.  This  step  insures  the  retention  of  enough  peritoneum  to  close 
the  peritoneal  wound  separately  at  the  end  of  the  operation. 

The  second  step  is  the  introduction  of  the  index  and  middle  fingers 
into  the  abdominal  cavity  to  elevate  the  fundus  ;  they  are  slipped  down  behind 
the  symphysis,  and  over  the  bladder  and  the  anterior  face  of  the  retroflexed 
uterus,  until  the  fundus  is  reached  on  the  pelvic  floor.     If  there  are  any  adhe- 


OPERATION. 


159 


sions  holding  it  down,  they  must  be  separated  bv  gradually  introducing  one  or 
two  fingers  behind  the  uterus  and  slowly  peeling  it  up,  breaking  the  adhesions  a 
few  at  a  time,  until  it  is  finally  freed.  Dense  adhesions  must  be  severed  with 
knife  or  scissors  under  inspection,  through  a  larger  incision,  carefully  drawino- 


Fig.  351. — Upper  Elevator. 

To  use  in  conjunction  with  the  lower  elevator  in  i.solating  and  holding  up  the 
uterus  during  the  passage  of  the  first  suspensory  suture.  The  upper  posterior  face  of 
the  uterus  lies  in  the  convexity  of  the  elevator.     3^  ordinary  size. 

the  uterus  away  from  the  rectum  and  pelvic  floor  so  as  to  make  a 
space  large  enough  to  cut  between  without  injuring  either  organ.  "When  the 
ovaries  and  tubes  are  so  diseased  as  to  require  removal,  the  uterus  is  taken  away 
too  instead  of  suspending  it. 

Two  fingers  are  hooked  under  the  retroflexed  fundus,  which  is  lifted  out  of 
its  bed  and  the  uterus  drawn  forward  until  the  fundus  lies  behind  the  symphy- 
sis, with  its  posterior  surface  turned  up  toward  the  incision.  If  the  intestines 
crowd  into  the  incision  so  as  to  embarrass  the  fingers  in  exposing  the  uterus,  a 


For  holding  up  the  uterus  for  suspension  when  the  pelvis  is  deep.    The  anterior  face  of 
the  uterus  rests  in  the  hollow  of  the  elevator.    3^  ordinary  size. 

sponge  slipped  down  behind  the  fundus  usually  clears  the  field. 
When  the  pelvis  is  deep,  or  the  abdominal  walls  thick,  or  the  uterus 
from  any  other  cause  is  diflicult  to  bring  into  view,  an  elevator  (see 
Fig.  352)  serves  as  a  temporary  artificial  point  of  support,  against 
which  the  uterine  body  is  held  while  the  first  suture  is  passed  through  the  fun- 
dus. The  elevator  used  in  this  way  gives  a  point  of  support  which  takes  the 
place  of  the  symphysis  under  ordinary  circumstances.  I  sometimes  use  two  ele- 
vators with  advantage,  one  in  front  and  one  behind  the  uterus.  The  same  end 
may  be  attained  by  catching  the  fundus  "^vith  a  pair  of  tenaculum  or  rat-toothed 
forceps,  draNving  it  up  into  the  incision,  and  holding  it  in  view  until  the  first 
suture  is  passed. 

Tlie  third  step  is  the  attachment  of  the  uterus  to  the  abdominal  wall;  • 
this  is  done  by  raising  one  side  of  the  lower  angle  of  the  incision  with  two  fin- 
gers in  order  to  expose  the  inner  surface ;  the  peritoneum  and  subperitoneal 
tissues  parallel  to  the  incision  are  now  transfixed  at  a  point  1  to  1^  centimeter 
away,  including  an  area  8  to  10  milHmeters  broad  (see  Figs.  354  to  350).  The 
fundus  uteri  is  next  transfixed  by  the  same  needle  carried  transversely  through 
a  part  of  the  posterior  surface  of  the  uteiiis  1  or  2  centimeters  below  a  line  con- 


160 


SUSPENSION    OF   THE    UTERUS. 


necting  the  uterine  tubes  ;  the  suture  takes  in  uterine  tissue  about  1  centimeter 
in  breadth  and  3  to  4  millimeters  in  depth.  The  needle  is  next  carried  through 
the  peritoneum  and  subperitoneal  tissue  on  the  opposite  side  of  the  incision  at 
a  point  corresponding  to  the  first  side.  The  intermediate  silk  suture  is  now- 
drawn  through  and  pulled  tight,  and  the  three  ])oints  transfixed  by  it— that  is, 
the  uterus  and  the  peritoneum  on  both  sides— are  brought  snugly  together. 

A  fino-er  is  introduced  before  tying  the  suture,  and  a  careful  examination  is 
made  to  make  sure  that  no  loop  of  intestine  or  bit  of  omentum  has  been  caught 

between  the  uterus  and  the  abdominal 
wall.  The  first  suspensory  suture  is 
then  tied  and  the  ends  cut  off  close  to 
the  knot.  A  second  suture,  re-enfor- 
cinir  the  first,  is  now  introduced  with 


V    '  rK  '^-'^  Vv 


Fio.  353. — Suspension  of  the  Uterus,  showing  Elevation  of  the  Uterus  with  the  Lower  Elevator. 
The  uterus  is  held  up  in  this  way  while  the  first  suture  is  passed. 

greater  ease  ;  it  transfixes  a  corresponding  portion  of  the  abdominal  wall  on 
both  sides  about  1  centimeter  above  the  first  suture  and  the  uterine  tissue  1 
centimeter  below  it ;  this  is  also  drawn  up  snugly,  tied,  and  cut  off  close  to 
the  knot. 

The  uterus  is  lifted  up  and  held  in  anteflexion  by  the  first  suture,  while  the 
second  brings  more  of  its  posterior  surface  into  contact  with  the  abdominal 


Fig.  354. — Suspension  ok  the  Uterl's. 

Showinj^  the  two  silk  suspensory  sutures  passing  through  the  peritoneum,  the  movable  subperitoneal  fat, 
and  connective  tissue  on  both  sides,  and  tlirougli  the  posterior  surface  of  the  uterus  in  the  middle.  The  suture 
nearest  the  symphysis  is  always  tied  before  introducing  the  second  suture. 


OPERATION. 


161 


Fig.  355. — Suspension  of  the  Uterus  as  seen  from  Above. 

The  uterus  is  attached  by  a  silk  suture  to  the  fundus  on  a 
line  posterior  to  the  uterine  tubes,  as  shown.  The  cut  edge« 
of  the  peritoneum  should  be  united  over  this  suspensory  suture; 
the  fascia  is  united  over  this,  and  the  skin  over  all. 


wall,  still  further  increasing  the  anteflexion.  More  than  two  sutures  are  not 
needed  unless  there  is  an  unusual  amount  of  dragging. 

Before  closing  the  abdomen 
the  omentum  is  drawn  down 
and  a  final  careful  examination 
is  made  by  slipping  the  finger 
over  the  posterior  surface  of 
the  uterus,  around  its  sides  and 
in  front  of  it,  to  make  sure 
that  no  loop  of  intestine  has 
been  caught  at  any  point. 

The  abdominal  incision  is 
closed  first  by  uniting  the  per- 
itoneum with  a  continuous  su- 
ture, then  the  remainder  of 
the  abdominal  wall  is  brought 
together  in  the  usual  manner 
with  a  single  buried  silver- 
wire  suture,  with  catgut  above 
and  below  it  for  the  fascia,  or 

by  using  catgut  alone  for  the  fascia,  and  catgut  for  the  fat  and  the  skin. 
In  some  cases,  in  order  not  to  leave  any  visible  scar,  I  have  opened  the  abdo- 
men by  making  a  transverse  incision  in  the  skin  just  below  the  line  of  growth 

of  the  pubic  hairs  ;  the  edges  of 
the  incision  were  then  drawn  up 
and  down  and  the  rest  of  the  in- 
cision made  in  a  vertical  direction. 
A  few  months  after  operation  such 
an  incision  is  entirely  concealed 
from  view. 

During  the  first  four  days,  if 
necessary,  the  bladder  should  be 
emptied  by  catheter  or  spontane- 
ously every  three  or  four  hours, 
and  after  that  the  interval  should 
not  be  longer  than  four  to  six 
hours.  Dr.  C.  P.  Noble  has  seen 
two  cases  in  which  the  suspensory 
sutures  have  been  pulled  out  dur- 
ing the  convalescence  by  an  over- 
distention  of  the  bladder.  His 
rule  is  alwavs  to  use  a  catheter  if 

Fig.  356. — Suspension  of  the  Uterus.  ,  .  "     .  .  ./. 

T..  ,     •      .,         ■  •       r  ,  •      .         there  is   persistent   pain,   even  ii 

J)ian:rani  showinfj  the  position  of  the  uterus  m  retro-  r                         r        ■> 

He.vion  in  dotted  line,  and  the  position  of  the  uterus  held  the  bladder  haS  jUSt  been  emptied, 

in  anteflexion  bv  the  two  suspensory  sutures.    Note  the  mi          i           i         i        i  i      i                      j 

yielding  of  the  peritoueuoi.  ihe      bowels     should      be      UlOVed 


162  SUSPENSION    OF   THE    UTERUS. 

forty-eight  hours  after  operation.  It  is  not  necessary  for  the  patient  to  remain 
lying  in  the  dorsal  position,  and  she  may  without  risk  be  gently  turned  on  either 
side  for  rest  or  sleep.  The  convalescence  is  managed  as  after  an  ordinary  ab- 
dominal operation,  with  the  additional  precaution  of  keeping  the  patient  three 
weeks  in  bed  and  urging  the  necessity  of  moderate  exercise  for  three  or  four 
weeks  longer ;  no  heavy  work  or  lifting  should  be  done  for  at  least  three 
months. 

Examinations  made  some  months  or  even  years  afterward  will  show  that  the 
cervix  lies  well  back  in  the  pelvis,  while  the  body  lies  in  anteflexion  with  the 
fundus  behind  the  symphysis.  The  body  is  separated  by  an  interval  of  2  or  3 
centimeters  from  the  abdominal  wall  by  the  stretching  of  the  adhesions  formed 
about  the  suspensory  sutures,  and  there  is  a  free  mobility  in  every  direction  ex- 
cept backward. 

I  summarize  an  analysis  of  75  cases,  made  from  one  to  two  years  after  opera- 
tion, by  Dr.  J.  E.  Stokes,  of  the  Johns  Hopkins  Hospital : 

Of  these  75  cases,  49  were  married  and  28  were  single.  The  49  married 
women  reported  14  pregnancies  ;  9  were  absolutely  normal ;  of  the  remaining 
5,  one  case  suffered  from  the  beginning  of  gestation  with  abdominal  pain ;  one 
patient  now  pregnant  feels  wu*etchedly,  with  pain  over  the  abdomen  ;  another 
case  miscarried  after  "  violent  dancing  "  ;  in  two  more  cases  the  "  placenta  was 
retained." 

In  general,  27  cases  were  entirely  relieved  of  their  discomforts,  37  were 
greatly  benefited,  and  11  were  unreheved. 


CHAPTEE   XXV. 

CONSERVATIVE   OPERATIONS   ON   THE   TUBES   AND   OVARIES. 

1.  What  conservatism  is. 

2.  Reasons  for  conservatism. — 1.  The  highest  aim  of  surgery.     2.  Importance  of  the  conserved 

structures:  a.  Mental  attitude  of  the  patient,  h.  Menstruation  important,  c.  Ovulation 
and  pregnancy  important,  d.  Internal  secretion.  3.  Better  knowledge  of  pelvic  diseases. 
4.  Only  the  diseased  portion  of  the  tube  or  ovary  need  be  removed.  5.  Regeneration  of 
diseased  tissues  is  often  possible.  6.  Removal  of  ovary  and  tube  together  for  purely  tech- 
nical reasons  not  necessary. 

3.  Relative  importance  of  ovaries,  uterus,  tubes. 

4.  Limits  of  conservatism. 

5.  Objections  to  conservatism. 

6.  Conservative  operations  on  the  ovary:   1.  Ovary  not  removed.— a.  For  tubal  disease.     6.  In 

many  cases  of  parovarian  cyst.  c.  In  extra-uterine  pregnancy,  d.  In  hystero-myomee- 
tomy.  2.  Ovarian  adhesions  (peri-oophoritis).  3.  Multiple  and"  small  Graafian  cysts.  4. 
Enlarged  cystic  Graafian  follicles.  5.  Cyst  of  corpus  luteum.  6.  Hematoma.  7.  Dermoid 
cysts.     8.  Ovarian  cystoma.     9.  Ovarian  abscess. 

7.  Conservative  opei-ations  on   the  uterine  tubes:    1.  Release  of  adherent  tubes.     2.  Opening  or 

resection  of  closed  tubes.  3.  Emptying,  cleansing,  or  sterilization  of  inflamed  tubes.  4. 
Amputation  of  diseased  tubes.  5.  Exsection  of  diseased  or  of  strictured  tubes.  6.  Drain- 
age of  tubal  abscess.  7.  Preservation  of  the  tube  or  closure  of  the  rent  in  some  cases  of 
extra-uterine  pregnancy. 

8.  Results  of  conservatism. 

9.  Cases  of  pregnancy  after  conservative  operations. 

Gynecological  conservatism  has  come  to  have  a  new  meaning  within  the 
past  ten  years,  and  it  is  now  the  distinctive  attitude  of  the  newer  and  better 
surgery  as  contrasted  with  the  widely  prevailing  radical  methods  of  the  last 
decade. 

Conservatism  is  the  effort  to  spare  as  much  as  possible  of  the  pelvic  organs 
during  an  operation,  and  to  conscientiously  avoid  the  removal  of  any  organ  or 
any  portion  of  an  organ  that  is  sound,  as  well  as  of  organs  or  parts  which,  though 
not  sound,  are  deemed  capable  of  regeneration  ;  or,  if  diseased,  to  avoid  remov- 
ing organs  whose  presence  is  not  incompatible  with  life  or  fair  health. 

Fifteen  years  ago  the  statement  that  an  operator  was  conservative  meant  that 
in  removing  a  diseased  ovary  and  tube  it  was  not  his  habit  to  remove  also  the 
opposite  sound  ovary  and  tube,  under  the  assumption  that  "the  disease  was 
liable  to  recur  in  the  opposite  side." 

Even  yet  the  pernicious  practice  prevails  in  some  places  of  removing  ovaries 
for  dysmenorrhea,  and  of  removing  ovaries  exhibiting  several  or  more  unrup- 
tured Graafian  follicles  under  the  assumption  that  they  are  diseased.  v 

It  is  only  a  few  years  since  the  rule  prevailed  widely  in  regard  to  pyosalpinx 
of  one  side  that  the  opposite  side  must  always  be  removed  too. 

The  first  telling  argument  in  behalf  of  conservatism  was  made  by  Sir  Sj)en- 
cer  AVells  {Ovarian  and  Uterine  Tumors,  London,  1882,  p.  342)  in  his  report  of 

163 


164  CONSERVATIVE    OPERATIONS    ON   THE   TUBES    AND    OVARIES. 

1,000  cases  of  ovariotomy  in  tabular  form,  with  a  note  of  the  after-history  of 
each  case. 

An  analysis  of  this  table  made  for  me  by  Dr.  J.  H.  Durkee  shows  that  the 
ovariotomy  was  unilateral — that  is,  that  one  ovary  was  left — in  228  women  who 
survived  the  operation  and  were  under  forty  years  of  age ;  of  these  228  women 
thus  left  capable  of  bearing  children,  120  actually  did  bear  230  children ;  to  the 
women  in  this  group  who  were  over  forty  years  of  age  four  children  were  born. 
That  is  to  say,  there  was  an  average  of  one  child  to  every  young  woman  with 
one  ovary  left  in,  and  there  was  a  recurrence  of  the  disease  in  the  remaining 
ovary,  necessitating  operation,  without  a  death,  in  but  six  women.  The  com- 
parison of  the  advantage  and  disadvantage  of  leaving  in  an  apparently  sound 
ovary  is  therefore,  in  each  case,  the  average  chance  of  having  one  child,  as  con- 
trasted with  the  risks  of  a  recurrence  of  the  disease  in  2*6  per  cent  of  the  cases. 
If  the  mortality  of  ovariotomy  is  5  per  cent,  then  the  risk  of  death  is  thirteen  to 
one  against  it  even  if  the  disease  does  recur. 

C.  Schroder  {Die  JEoecision  von  Ovarientumoren  mit  Erhaltung  des  Ova- 
rium. Zeitschrift  f.  Geb.  und  Gyn.,  Bd.  xi,  1885,  p.  358),  by  the  resection  of 
the  ovaries,  A.  Martin  {Ueber  partielle  Ovarien  und  Tuhen  Extirpationen. 
Samm.  Min.  Vort.,  1889,  p.  2481),  in  the  resection  of  ovaries  and  in  opening 
closed  tubes  and  by  extensive  myomectomies,  and  Dr.  W.  M.  Polk  {Are  the 
Tubes  and  Ovaries  to  he  sacrijiced  in  all  Oases  of  Salpingitis  f  Trans.  Amer. 
Gyn.  Soc,  vol.  xii,  18-87),  by  his  repeated  demonstrations  and  earnest  insistence 
upon  the  possibility  of  restoration  of  function  in  diseased  adherent  tubes  and 
ovaries  and  of  the  functional  value  of  opened  and  amputated  tubes — have  all 
helped  to  lay  the  foundation  stones  for  the  important  conservative  gynecological 
work  in  the  immediate  future. 

The  reasons  for  Conservatism  are  : 

1.  That  it  is  the  general  attitude  of  all  true  surgery. 

2.  The  important  uses  and  relation  of  the  conserved  structures  to  the  human 
organism. 

3.  The  recognition  that  what  were  once  considered  diseases  of  the  tubes  and 
ovaries  are  in  many  instances  no  diseases  at  all. 

4.  The  recognition  that  a  disease  of  part  of  a  structure,  ovary,  tube,  or 
uterus  may  only  demand  the  removal  of  that  portion  which  is  diseased. 

5.  The  discovery  that  in  certain  diseases  an  entire  regeneration  may  take 
place  and  badly  diseased  tubes  may  again  become  normal  in  their  functions. 

6.  On  account  of  the  value  of  the  structures  involved,  ovary  and  tube  are 
no  longer  removed  en  masse  for  purely  technical  reasons,  but  a  diseased  tube  or 
part  of  a  tube,  a  diseased  ovary  or  part  of  an  ovary,  are  removed  by  themselves, 
each  without  interfering  with  the  other. 

1.  Conservatism   the   highest   aim   of   surgery. 

It  is  almost  an  aphorism  in  general  surgery  that  exsective  surgery  is  its  op- 
probrium, and  no  conscientious  surgeon  removes  a  limb  or  part  of  the  body 
which  could  be  restored  to  its  usefulness  by  a  careful  conservative  treatment.  I 
shall  never  forget  the  impression  made  upon  me,  as  a  hospital  resident  in  1882, 


KEASOXS    FOK    CONSERVATISM.  165 

when  I  saw  a  boy  brought  ill  with  a  clean  compound  fracture  of  one  forearm 
and  simple  fractures  of  the  radius,  ulna,  and  humerus  of  the  other  arm,  and  the 
surgeon  amputated  both  arms  ! 

If  the  traditions  of  surgery  and  its  best  principles  all  point  toward  conserva- 
tism as  its  highest  goal,  there  is  no  reason  for  making  any  exce]3tions  to  these 
rules  in  the  special  field  of  gynecological  surgery. 

2.  The  importance  of  the  conserved  structures  to  the  wel- 
fare of  the  patient. 

The  pelvic  organs  are  indelibly  associated  in  a  woman's  mind  with  those 
fundamental  differences  between  the  sexes  which  impress  upon  the  female  or- 
ganism all  that  is  distinctive  and  peculiar  in  her  attitude  toward  the  world  at 
large ;  and  with  the  healthy  performance  of  her  functions  in  the  recurring 
monthly  fluxes,  ovulation,  and  the  possibility  of  conception,  lie,  though  the 
woman  may  be  unconscious  of  it,  some  of  the  deepest  wellsprings  of  her  hap- 
piness. 

The  effect  of  the  removal  of  the  sexual  organs  in  woman  is,  in  many  in- 
stances, entirely  analogous  to  the  corresponding  operation  upon  a  man,  disturb- 
ing her  psychical  and  physical  balance,  and  bringing  on  a  state  of  wretched 
confusion  in  the  new  and  anomalous  relationship  in  which  she  finds  herself. 

Menstruation  has  often  been  denounced  as  a  useless,  troublesome  function, 
entailing  discomforts  and  impeding  woman's  progress  in  all  comjDetitive  work,  but 
we  are  now  beginning  to  realize  that  so  long  as  its  cyclical  changes  persist,  they 
hold  most  important  fundamental  relations  to  the  well-being  of  the  body  at 
large  ;  and  while  we  are  as  yet  unable  to  state  what  is  definitely  accomplished 
by  the  act  in  the  way  of  excretion,  or  its  influence  on  metabolism,  we  do  know 
that  the  sudden  artificial  induction  of  the  menopause  is  often  a  source  of  ex- 
treme and  lasting  discomforts  (see  Chapter  XXVI).  It  is  still  a  matter  for 
future  demonstration  whether  or  not  these  sequelae  are  in  all  cases  obviated  by 
leaving  in  one  or  both  ovaries  when  the  uterus  and  tubes  are  removed  and  men- 
struation so  checked. 

Ovulation  and  pregnancy  under  suitable  conditions  are,  to  a  degree  utterly 
unappreciable  to  the  male  mind,  essential  elements  of  woman's  happiness.  To 
dwell  upon  this  point  would  be  but  to  reiterate  what  any  attentive  surgeon  may 
gather  from  his  daily  experience  in  the  consulting  room,  and  to  rehearse  well- 
known  facts  in  the  history  of  womankind. 

C.  Schroder  stated  that  one  of  his  reasons  for  the  preservation  of  part  of 
an  ovary  was  to  preserve  the  function  of  ovulation,  even  if  it  were  ac- 
companied by  but  a  theoretical  possibility  of  concep- 
tion. I  have  dwelt  in  another  chapter  on  the  profound  psychic  changes 
and  melancholia  often  brought  on  by  the  surgical,  forcibly  induced  meno- 
pause. 

Internal  Secretion. — There  is  a  growing  conviction  that  the  ovary 
belongs  to  the  same  group  of  organs  as  the  thyroid,  thynuis,  and  pineal  glands, 
and  that,  in  addition  to  its  function  of  ovulation,  it  secretes  a  substance  which  is 
absorbed  and  consumed  in  the  animal  economy,  and  which  is  necessary  to  it  in 


166  CONSERVATIVE    OPERATIONS    ON   THE   TUBES    AND    OVARIES. 

retaining  its  physiological  balance  (see  C.  H.  F.  Routh,  Brit  Gyn.  Jour.,  May, 
1894). 

The  argument  in  behalf  of  the  existence  of  this  substance,  which  we  might 
call  "  ovarine  "  were  it  not  for  the  illegitimate  trade  uses  for  which  this  term  has 
been  appropriated,  does  not  yet  rest  upon  the  basis  of  an  absolute  demonstra- 
tion, but  rather  upon  the  strong  analogy  which  may  be  drawn  between  the  ovary 
and  the  internal  secretive  glands  named,  and  as  evidenced  by  the  disastrous  con- 
sequences following  its  removal  during  the  period  of  its  functional  activity. 
C.  Martin  says  {Brit.  Gyn.  Jour.,  N'ov.  1893,  p.  273):  "It  is  probable  that 
the  ovaries,  like  the  liver  and  thyroid  gland,  modify  the  blood  circulating 
through  them,  and  add  to  the  blood  some  peculiar  product  of  their  metabolism. 
It  may  be  that  some  of  the  climacteric  symptoms  are  due  to  the  loss  of  this 
substance  from  the  system." 

An  active  principle  called  "  spermin,"  found  in  sperm  by  Schreiner  in  1878, 
has  been  found  in  the  thyroid  and  thymus  glands,  and  in  the  S2)leen,  ovaries, 
testes,  and  blood,  from  all  of  which  it  has  been  extracted  in  the  form  of  an  in- 
soluble spermin  phosphate. 

A.  Poehl  (Z.  Erkl.  d.  Wirk.  d.  Spermins  als.  jAysiol.  Tonicum  auf  die 
Autointoxicationen.  Be?'!.  Tdiii.  Woch.,  Sept.  4,  1893,  p.  873)  has  elaborately 
studied  this  product,  and  found  it  in  both  the  male  and  the  female  reproductive 
organs,  and  as  a  normal  physiological  constituent  of  the  prostate,  testicles,  ova- 
ries, thyroid,  thymus,  pancreas,  and  spleen,  as  well  as  in  the  blood. 

The  crystals  of  spermin  were  separated  from  the  semen  in  a  form  similar  to 
the  Charcot-Leyden  crystals  of  Boettcher,  with  which  they  were  for  a  long  time 
confused.  Spermin  is,  as  A.  Gautier  has  declared,  a  leukomain  believed  until 
recently  to  be  a  product  of  the  retrogressive  metamorphosis  of  an  albumen, 
either  injurious  or  indiiferent  to  the  organism ;  evidences  now  in  hand,  how- 
ever, go  to  show  that  spermin  possesses  most  valuable  functions  in  connection, 
with  the  activities  of  living  beings,  and  the  spermin  secreting  and  elaborating 
organs  may  he  called  the  "  apothecaries "  of  the  body,  secreting  many  impor- 
tant medicaments  much  more  active  and  more  accurately  representing  its  true 
wants  under  varying  conditions  than  any  artificially  administered  drugs. 

Spermin  is  an  active  oxidizing  agent,  assisting  by  its  catalytic 
action  in  restoring  the  oxidizing  power  of  the  blood  without  having  recourse 
to  the  oxygen  derived  from  the  air;  this  action  ifi  remarkably  illustrated  by 
the  introduction  of  a  small  quantity  of  spermin  with  metallic  magnesium 
into  a  watery  solution  of  the  chlorides  of  the  noble  metals,  and  some  others 
(AuCl3,CuCl2,  etc.),  when  the  metal  is  converted  into  magnesium  oxide,  the 
needed  oxygen  being  taken  from  the  water. 

Spermin  has  shown  a  favorable  action  when  given  to  patients  suffering  from 
diabetes,  scurvy,  etc.,  in  which  auto-intoxications  are  manifestly  the  result  of 
an  accumulation  of  retrograde  products ;  injected  subcutaneously,  it  acts  as  a 
physiological  tonic  in  all  kinds  of  depressed  conditions,  such  as  neurasthenia, 
anemia,  etc.  Poehl  declares  that  it  increases  the  nitrogenous  excreta  of  the 
kidneys.     Its  action  is  enhanced  by  the  alkaline  condition  of  the  blood. 


REASOXS    FOR    CONSERVATISM. 


16: 


More  positive  evidences  for  an  internal  secretion  of  the  ovary  are  furnished 
by  the  experunents  upon  bitches  made  by  G.  E.  Curatulo  and  L.  TarulH  {La 
Secrezione  Interna  delle  Ovaie^  Rome,  1896). 

These  authors,  after  regulating  the  diet  of  the  animals  until  a  certain  average 
quantity  of  nitrogenous  materials  and  phosphates  were  excreted  daily,  removed 
the  ovaries.  In  each  experiment  they  found  the  phosphates  (PaOj,)  i  n 
the  urine  greatly  and  permanently  reduced  in  quantity. 
In  one  case,  where  the  nitrogenous  materials  averaged  9'93  grammes  and  the 
phosphates  1'5  gramme,  a  series  of  daily  observations  was  continued  over  three 
months,  and  demonstrated  the  fact  that,  while  the  nitrogen  remained  about  the 
same  in  quantity,  the  phosphates  decreased  down  to  0*6  gramme. 

These  data  are  of  such  great  importance  as  aiiording  one  of  the  most  tangible 
evidences  as  yet  offered  of  the  existence  of  this  third  secretive  ovarian  function 
that  I  present  here  three  of  the  tables  taken  from  their  book,  in  condensed 
form.  The  upper  line  of  figures  in  each  case  shows  the  condition  of  the  bitch 
before  operation  ;  following  this  are  given  the  dates  of  the  succeeding  observa- 
tions and  the  condition  of  the  animal  at  each  date ;  the  last  line  shows  what  may 
be  considered  as  the  average  effect  of  the  castration  upon  the  urine  some  months 
after  operation. 

Table  shoiving  the  Effect  of  Castration  upon  the  Composition  of  Urine. 


Date. 


November  14 
December  14. 
January  14  . . 
February  14  . 

March  9 

April  24 

May  o 

June  23 

July  12 

March  9 

April  9 

May  8 

June  9 

July  6 

April  15 

May  15 

June  15  


Weight  of 

animal, 

gr. 


Urine  in  24 
hours. 


Azote  elim- 
inated, 
gr. 


PjOs  emitted, 
gr. 


Dog  A,  both  ovaries  taken  out  November  15. 


9,500 

7,520 

8.720 

9,750 

10.260 

9,220 

10.200 

10,170 

11,900 


795 
740 
910 
960 
860 
960 
1,065 
680 
700 


9-230 

9-870 
10-310 
10-870 
10-790 

9-060 
10-600 

9-100 
10-690 


Dog  B,  both  ovaries  removed  IMarch  10. 


11.160 
12,800 
13,900 
1,500 
10,459 


840 
870 
900 
700 
620 


13-64 
13-40 
14-20 
12-93 
13-20 


710 
740 
700 
665 
650 
576 
860 
460 
560 


Dog  C.  uterus  and  ovaries  removed  April  24. 
5.250  470  7-13  0-65 

5.650  530  7-18  0-32 

6,300  500  6-86  0-27 


These  experiments  also  explain  the  utility  of  castration  for  the  relief  of 
osteomalacia,  in  jiermanently  diminishing  to  such  a  marked  degree  the  excretion 
of  the  lime  salts  which  go  to  form  the  solid  elements  of  the  bones. 

Associating  Ciiratulo's  results  with  the  evidence  given  by  Poehl  of  the  high 
oxidizing  power  of  "  spennin,"  we  may  attribute  the  effects  of  castration  in  de- 


168  COXSEKVATIVE    OPERATIONS    ON   THE   TUBES    AND    OVARIES. 

creasing  the  phosphates  in  the  urine,  not  to  the  lessened  quantity  taken  in  the 
food,  but  to  a  diminished  oxidation  of  the  organic  phosphates  contained  in  the 
tissues,  which,  combined  with  earthy  bases,  are  finally  deposited  in  the  bones  in 
the  form  of  calcium  and  magnesium  phosphates. 

Routh  {id  siij).)  gives  further  important  evidence  of  the  existence  of  an  in- 
ternal ovarian  secretion  in  citing  Dr.  Airstoffs  investigations,  which  show  that 
when  one  ovary  is  removed  in  a  rabbit  the  other  under- 
goes a  compensatory  hypertrophy  increasing  both  in  size  and 
weight,  the  follicles  mature  and  wither  more  quickly,  and  the  medullary  por- 
tion increases.  These  changes  begin  within  two  months  after  the  operation,  and 
in  three  or  four  months  the  remaining  ovary  has  become  nearly  double  its  ori- 
ginal size. 

Since  the  ill  effects  of  castration  in  women,  whether  the  structures  are 
diseased  or  not,  are  often  so  disastrous,  it  becomes  a  question  of 
paramount  importance  to  determine  whether  we  can  in 
any  way  substitute  the  lost  ovarian  tissue,  and  to  this  end 
two  natural  lines  of  experiments  have  been  ti'ied.  E.  Knauer  {Cen.  f.  Gyn., 
No.  20,  May  16,  1896,  in  a  communication  entitled  Einige  Yersuche  uher  Ova- 
rientransplantation  bei  Kaninchen)  has  shown  that  the  ovaries  may  be 
completely  severed  from  their  normal  surroundings  and 
successfully  transplanted  either  to  a  part  of  the  broad  ligament  or 
between  the  muscles  of  the  abdominal  wall. 

In  one  of  the  rabbits  experimented  upon  and  examined  six  months  after 
the  transplantation,  one  ovary  excised  and  implanted  in  the  broad  ligament  was 
found  as  big  as  a  lentil  and  abundantly  nourished,  with  a  normal  stroma  and 
numerous  follicles  of  all  sizes  containing  ovules ;  a  number  of  degenerated 
follicles  was  also  found,  perhaps  more  than  usual.  An  ovary  implanted  in  the 
fascia  of  the  abdominal  wall  was  only  about  a  third  its  original  size,  but  was  in 
other  respects  normal. 

The  important  conclusion  may  therefore  be  drawn  that  the  ovaries  may  be 
transplanted  even  to  a  distant  point  differing  widely  from  their  normal  habitat, 
where  they  will  not  only  grow,  but  will  also  continue  to  develop  normal  Graafian 
follicles.  It  still  remains  to  be  shown  whether  these  follicles  rupture,  and  of 
what  use  transplanted  ovaries  may  be  to  the  animal  economy. 

The  second  line  of  experimental  substitution  of  the  lost 
ovarian  tissue  is  that  of  feeding  to  the  women  deprived 
of  their  ovaries  one  of  the  various  organic  juices.  This 
has  been  tried  by  R.  Chrobak  {Centr.  f.  Gyn.,  No.  20,  May  16,  1896}  in  a  few 
cases  with  distinctly  encouraging  results. 

The  ovaries  of  cows,  washed  in  ether  and  alcohol  and  dried  at  a  temperature 
of  45  to  50°  C.  with  an  air  pump,  and  then  pulverized  and  made  into  tablets  con- 
taining 0*2  gram  of  ovarian  substance  each,  were  used.  Two,  three,  or  even 
four  of  these  tablets  were  given  daily  to  women  suffering  from  the  severe  symp- 
toms of  an  induced  climacteric ;  in  one  case,  after  taking  two  or  three  tablets 
daily,  the  attacks  of  giddiness,  flushes,  and  sweatings,  which  the  patient  had  been 


REASOXS    FOR    COXSERVATISil.  1G9 

having  on  an  average  of  ten  times  daily,  wei*e  reduced  to  three,  and  disap- 
peared entirely  at  night ;  another  patient  was  entirely  relieved  of  attacks  which 
had  been  distressing  her  five  or  six  times  a  day ;  in  another  case,  with  frequent 
attacks,  as  many  as  twenty  a  day,  they  were  reduced  one  half. 

If  the  ovary  and  thyroid  gland  both  secrete  a  similar  princij^le,  spermin,  or 
if  the  ovary  secretes  a  principle  which  is  then  elaborated  for  use  by  the  thyroid 
gland,  it  is  manifest  that  good  results  might  be  expected  by  the  administration 
of  the  thyroid  gland,  or  of  the  thyroid  extract,  for  it  shows  such  remarkable 
powers  of  retaining  its  identity,  even  in  the  presence  of  mineral  acids,  that  it 
might  well  be  expected  to  withstand  also  the  chemistry  of  digestion. 

A  valuable  contribution  to  this  line  of  observation  has  been  made  by  Dr.  H, 
B.  Stehman,  of  Chicago  {Atner.  Gyn.  and  Ohs.  Jour.,  Feb.,  1897),  who  gave 
thyroid  tablets  to  a  series  of  patients,  suffering  from  various  forms  of  mental 
and  other  disturbances,  such  as  excessive  flow,  amenorrhea,  extreme  nervousness, 
and  ovarian  pains,  all  of  which  might,  under  the  present  hypothesis  of  the  func- 
tion of  the  internal  secretions,  be  attributed  to  deficient  ovarian  secretion. 

Each  tablet  given  three  times  daily  represented  about  one  sixth  of  a  sheep's 
thyroid.  In  each  of  the  six  cases  such  a  remarkable  improvement  was  observed 
within  several  weeks  that  the  conclusion  seems  well-founded  that  "  in  those  cases 
of  neurasthenia,  with  poor  nutrition,  and  in  consequence  disordered  pelvic  func- 
tion, ovarian  tissue  is  indicated.  The  extract  not  only  modifies  the  nutrition 
of  the  ovary,  but  also  general  nutrition,  and  this  return  to  the  normal  makes 
physiologic  processes  possible."  There  exists  probably  "  an  intimate  nutritive 
relation  between  the  pelvic  generative  organs  and  the  thyroid,  and  the  ovary 
shares,  too,  in  some  mysterious  manner  in  the  processes  of  general  metabolism." 

3.  A  fui'ther  reason  for  the  advance  made  in  conservatism  is  the  m  ore 
intelligent  discrimination  exercised  in  regard  to  pelvic 
diseases,  the  result  of  broader  clinical  observations,  associated  with  careful 
microscopic  examinations  of  tissues  removed.  This  has  had  the  effect  of  com- 
pelling gynecologists  in  general  to  abandon  all  enucleations  of  "  cystic  ovaries," 
except  in  rare  cases  where  the  ovary  is  so  greatly  hypertrophied  as  to  be  con- 
verted simply  into  an  aggregation  of  cysts  with  the  albuginea  greatly  thick- 
ened. A  few  prominent  cysts  with  clear  walls  often  exhibited  in  the  past  as 
evidences  of  a  "cystic  degeneration"  are  now  considered  as  either  entirely  nor- 
mal, or  so  near  normal  as  never  of  themselves  to  justify  the  removal  of  the  ovary. 

"  Cirrhosis  of  the  ovary  "  is  still  another  much-abused  term,  used  even  yet 
to  describe  the  product  of  a  chronic  inflammation  of  the  ovary  which  does 
not  exist  as  a  pathological  entity.  The  so-called  cirrhotic  ovaries  are  simply 
contracted  hard  bodies,  for  the  most  part  the  result  of  a  protracted  malnutrition 
of  the  organ,  often  due  to  displacement  and  surrounding  adhesions  binding  it 
down  and  cutting  off  its  circulation. 

Adhesions  of  the  uterus  and  adhesions  surrounding  the  tubes  and  ovaries  are 
often  but  the  evidences  of  an  old  attack  of  pelvic  peritonitis  due  to  an  infection 
starting  in  the  mucous  surface  of  the  uterus  and  propagated  through  the  uterine 
tube ;  the  original  disease  has,  in  many  instances,  long  since  run  its  course,  and 


170        COXSERVATIVE  OPERATIONS  ON  THE  TUBES  AND  OVARIES. 

the  Ijmph  bands  and  adhesions  left  behind  uniting  the  peritoneal  surfaces  of 
the  pelvic  viscera  do  not  signify  any  existing  disease  of  the  organs  themselves. 
If  these  adhesions  are  severed  and  the  accidentally  imprisoned  organs  released, 
there  is  no  reason,  in  many  instances,  why  their  normal  functions  should  not 
be  re-established  and  the  symptoms  relieved  without  extirpation. 

In  this  connection  C.  C.  Burrows  {A?ner.  Jour.  Ohst.^  vol.  xxviii,  No.  6, 
1893)  furnishes  us  with  a  most  instructive  case  of  regeneration.  A  patient  was 
operated  upon  and  a  purulent  tube  and  ovary  were  removed  from  the  right 
side ;  adhesions  about  the  left  tube  and  ovary  were  broken  up,  the  closed  end  of 
the  tube  was  opened,  and  the  cystic  ovary  was  resected,  about  one  third  of  it 
being  removed.  On  opening  the  abdomen  a  year  later  to  cure  a  ventral  hernia, 
the  tube  and  the  ovary  were  found  free  from  adhesions  and  perfectly  healthy, 
the  fimbriated  extremity  was  open,  and  no  evidences  of  the  ovarian  resection 
could  be  found ;  the  health  of  the  patient  was  perfect  except  for  the  hernia. 

The  general  rule  may  then  be  laid  down  that  adhesions 
of  the  ovaries  and  tubes  to  the  pelvic  floor,  pelvic  walls, 
or  to  the  broad  ligaments,  uterus,  and  intestines,  never 
constitute  j>e/'  se  a  valid  reason  for  the  removal  of  these 
structures,  and  if  these  organs  are  removed  the  reason 
for  the  extirpation  must  be  grounded  in  the  actual  con- 
dition   of   the   organ   itself. 

4.  When  the  disease  affects  only  a  portion  of  a  struc- 
ture, the  rule  is  that  the  diseased  portion  should  be  re- 
moved  and   as   much   as   possible   of   the   sound   tissue   left. 

For  example,  if  the  outer  extremity  of  the  uterine  tube  is  extensively 
altered  by  cicatricial  changes  the  end  of  the  tube  may  be  amputated  with  a  good 
hope  of  restoring  its  function ;  this  procedure  will  be  illustrated  in  discussing 
the  technique  of  conservative  operations. 

If  an  ovary  shows  cystic  degeneration,  the  cyst,  whether  Graafian  or  corpus 
luteum  follicle,  may  be  exsected  and  the  sound  tissue  left.  Even  in  the  case  of 
small  ovarian  abscesses,  2  to  4  centimeters  in  diameter,  I  should  advocate  open- 
ing the  abscess,  removing  its  lining  membrane  or  curetting  it,  and  sewing  up 
and  saving  the  ovary. 

There  is  the  best  clinical  evidence  to  show  that  even  a  small  bit  of  ova- 
rian tissue  left  behind,  or  the  stump  of  an  amputated  tube,  may  not  only  per- 
form its  ordinary  functions,  but  may  even  contribute  and  carry  an  ovum  to  be 
lodged  in  the  uterus,  and  go  through  tlie  evolutions  of  a  normal  pregnancy. 

5.  The  regeneration  of  inflamed  tissues  has  also  been  abun- 
dantly demonstrated  by  the  best  clinical  evidences ;  after  draining  large  pelvic 
abscesses,  the  pelvic  organs  have  at  a  later  date  been  found  perfectly  restored ; 
uterine  tubes  presenting  a  parenchymatous  salpingitis  have  been  dropped  back 
and  later  found  healthy,  and  the  beet  evidence  of  their  perfect  function  given 
by  the  occurrence  of  pregnancy. 

In  hydrosalpinx,  although  distended  and  thinned  by  the  pressure  of  the 
accumulated  fluid,  the  tubal  walls  preserve  their  normal  epithelial  covering,  and 


LIMITATIOXS    OF    COXSERVATISM.  171 

after  opening  the  ostium  or  cutting  off  the  ampullar  end  the  tubes  may  resume 
their  functions  perfectly. 

G.  The  sacrifice  of  the  tube  and  o v ary  is  often  due  to 
purely  technical  reasons  on  account  of  the  habit  of  operators  of 
clinging  to  a  traditional  method  of  removing  the  tul)e  and  the  ovary,  pulling 
them  up  together,  and  transfixing  and  tying  them  off  in  a  bunch. 

By  the  exercise  of  a  more  intelligent  judgment  and  with  better  skill  the  op- 
erator will  no  longer  be  eml)arrassed  in  removing  either  tube  or  ovary  alone,  or 
a  piece  of  the  tube,  or  a  portion  of  the  ovary. 

For  the  same  unintelligent  technical  reason  both  tube  and  ovary  have  been 
extirpated  in  removing  parovarian  cysts  in  which  it  is  frequently  possible  by  a 
simple  carefully  conducted  dissection  to  extirpate  the  cyst,  leaving  behind  the 
otherwise  unaffected  structures. 

Relative  Importance  of  Ovaries,  TJterus,  Tubes. — In  all  intelligent  conservative 
efforts  the  various  important  objects  of  the  conservatism  must  l)e  borne  in  mind, 
and  these  are,  first,  the  complete  restoration  of  all  the  functions  without  pain ; 
second,  to  preserve  menstruation  and  ovulation ;  third,  to  put  the  organs  in  con- 
dition to  make  pregnancy  possible ;  fourth,  to  preserve  ovulation  and  the  in- 
ternal ovarian  secretion,  even  though  the  menstruation  and  possible  conception 
have  to  be  sacrificed. 

In  each  of  these  four  categories  the  ovanes  are  essential,  for,  with  the  re- 
moval of  the  ovaries,  ovulation,  internal  secretion,  and  menstruation  cease ;  the 
ovaries  are  therefore  the  organs  of  paramount  importance,  and  ^vithout  them 
both  uterine  tubes  and  uterus  are  useless. 

So  extremely  important  are  the  ovaries  that,  if  the  circumstances  justify  it, 
even  a  small  piece  of  sound  ovarian  tissue  should  be  preserved. 

Next  in  importance  to  the  ovaries  comes  the  uterus,  for  with  the  ovaries  and 
the  uterus  ovulation,  internal  secretion,  and  menstruation  may  continue  with  due 
regularity. 

There  is  no  reason  to  believe  that  the  tubes  without  the  uterus  and  ovaries  are 
of  any  use ;  their  value  is,  however,  enhanced  by  the  presence  of  even  a  small 
bit  of  ovarian  tissue  to  such  a  degree  that  one  or  both  mutilated  tubes  may  often 
be  preserved  with  advantage  under  these  circumstances,  and  pregnancy  occur. 

Limitations  of  Conservatism. — Both  Nature  and  disease  impose  upon  our  con- 
servative efforts  several  easily  definal)le  limitations. 

After  a  woman  has  reached  the  forties,  when  reparative  processes  in  disease 
are  not  as  active,  and  when  age  makes  pregnancy  less  likely,  even  under  normal 
conditions,  and  especially  after  the  menopause,  one  important  reason  for  con- 
servatism— namely,  a  chance  of  conception — loses  its  force. 

This  limitation,  however,  affects  only  the  uterine  tubes,  whose  sole  function 
is  to  act  as  transmitters  of  the  ova.  The  ovaries  and  the  uterus,  on  the  other 
hand,  are  of  value  so  long  as  menstruation  persists,  for  severe  nervous  disturb- 
ances may  arise  from  the  removal  of  both  these  organs  even  in  the  forties. 

No  age  liuiit  can  be  set  upon  the  utility  of  the  ovaries  until  it  has  been 
demonstrated  that  the  internal  secretion  also  ceases  with  the  menopause,  a  eon- 

52 


172  CONSERVATIVE    OPERATIONS   ON   THE   TUBES    AND    OVARIES. 

elusion  which  is,  for  the  present  at  least,  apparently  at  variance  with  the  clinical 
facts.  Inasmuch,  however,  as  the  ovary  has  lost  at  least  two  of  its  important 
uses  (ovulation  and  menstruation),  less  hesitation  should  be  felt  in  sacrificing  it 
in  the  presence  of  disease. 

Malignant  disease  of  an  ovary  has  been  generally  recognized  not  only  as  con- 
stituting the  strongest  possible  indication  for  its  i-emoval,  but  for  tlie  removal  of 
its  fellow  as  well,  whether  apparently  diseased  or  not.  I  can  not  concur  in  this 
sweeping  conclusion,  and  in  the  event  of  discovering  such  a  disease  as  a  super- 
ficial papilloma  of  one  ovary  at  the  very  beginning,  if  the  other  ovary  appeared 
perfectly  normal,  I  should  without  hesitation  save  it  in  a  young  woman,  with 
the  expectation  of  carefully  watching  the  patient  for  several  years,  and  of  operat- 
ing at  once  upon  detecting  the  slightest  evidence  of  disease. 

Tumors  of  the  ovaries  of  the  connective-tissue  group  usually  forbid  any  con- 
servative efforts,  as  they  commonly  involve  the  entire  organ. 

Objections  to  Conservatism. — Among  the  objections  urged  against  conserva- 
tism, that  of  the  liability  of  the  disease  to  recur  in  the  op^josite  side  or  in  the 
parts  left  behind  is  the  most  important.  "When  the  disease  is  not  of  a  serious 
nature,  as  in  the  case  of  Graafian  or  corpus  luteum  cysts,  there  is  no  evidence  to 
show  that  the  remaining  parts  are  in  any  way  peculiarly  liable  to  disease,  and  the 
burden  of  proof  still  rests  upon  those  who  object  to  conservatism. 

In  unilateral  inflammatory  disease,  which  is  for  the  most  part  propagated 
from  the  uterus,  it  is  true  that  the  opposite  side  may  subsequently  go  through 
the  same  changes,  but  there  is  no  more  reason  for  extirpating  apparently  sound 
organs  than  there  is  for  recommending  the  removal  of  all  infected  uteri,  unless 
it  is  that  the  open  abdomen  makes  the  operation  a  convenient  one. 

When  both  tubes  exhibit  different  stages  of  the  same  disease,  and  one  is 
choked  with  pus  and  the  other  only  thickened  and  inflamed,  the  question  of 
conservatism  is  a  more  difficult  one,  because  the  chances  of  the  disease  progress- 
ing in  the  healthier  side  are  greater.  If,  however,  the  patient  has  expressed 
willingness  to  run  the  risk  of  a  second  operation,  the  surgeon  should  be  glad, 
upon  removing  the  worst  side,  to  release  all  adhesions  and  to  squeeze  out  and 
wash  out  the  other  tube,  and  then  to  dilate,  curette,  and  drain  the  uterus,  in 
hopes  of  cutting  short  the  process  in  this  way. 

The  objection  that  adherent  and  inflamed  structures  are  either  so  far  de- 
stroyed or  crippled  by  the  disease  as  to  be  beyond  Nature's  reparative  processes 
is  not  borne  out  by  the  facts  now  abundantly  laid  before  the  profession.  It  has 
also  been  stated  that  the  risks  of  an  extra-uterine  pregnancy  were  a  serious  ob- 
jection to  conservative  operations  upon  organs  either  in  themselves  diseased  or 
else  implicated  in  neighboring  disease,  and  while  this  argument  demanded 
careful  consideration  at  first,  the  fact  that  no  case  has  ever  yet  l)een  rejDorted  is 
a  sufficient  answer  to  it.  There  is  no  risk  of  infection,  sepsis,  and  death  in 
operations  upon  non-inflammatory  cases,  such  as  resection  of  the  ovary,  etc.  In 
inflammatory  cases  the  risk  is  not  increased  in  the  absence  of  pus,  but  in  some 
forms  of  pelvic  abscess  the  risk  may  be  very  great. 

The  history  of  the  case  and  the  severity  of  the  inflammatory  process  asso- 


CONSERVATIVE    OPEKATIOXS   OX    THE    OVARY,  173 

ciated  with  a  microscopic  examination  of  the  pus  during  the  operation  will  often 
guide  the  operator  as  to  the  advisability  of  opening  up  and  washing  out  and 
leaving  the  pus  tube  or  an  ovarian  abscess. 

In  the  presence  of  nuuierous  cocci,  presumably  streptococci,  I  should 
not  attempt  to  preserve  the  structure  in  which  they  were  found,  but  I  should 
not  hesitate  to  treat  abscesses  showing  g  o  n  o  c  o  c  c  i,  or  sparse  cocci  or 
bacilli  of  any  other  sort,  by  carefully  cleansing  them  and  restoring  the  organs 
with  or  without  a  vaginal  drain,  according  to  the  extent  of  the  disease. 

The  published  records  so  far  do  not  show  any  increase  in  the  mortalitv  from 
conservatism  of  this  sort. 

The  risk  to  life  from  a  second  operation  is  not  often  increased  by  the  first 
operation ;  the  abdominal  scar  may  be  easily  excised,  and  if  a  considerable  part 
of  the  disease  has  been  removed,  the  second  operation  is,  as  a  rule,  much  easier 
than  the  first.  It  is  true  that  the  pain,  often  to  tlie  patient  the  one  prominent 
symptom,  may  persist  and  prove  the  conservatism  in  any  particular  case  to  have 
been  ill-advised ;  but,  to  refer  again  to  recorded  cases,  the  patients  who  have 
continued  to  complain  constitute  a  small  minority — much  smaller  than  the  per- 
centage complaining  after  the  exsective  operations  of  a  few  years  ago. 

In  general  the  best  reply  to  all  these  objections  is  the  assertion  of  the  pa- 
tient's inalienal)le  right  in  all  cases  to  decide  that  her  pelvic  organs  shall  not  be 
sacrificed  under  any  possible  complication  of  conditions  which  may  exist,  and 
the  conscientious  surgeon  will  always  abet  her  in  her  willingness  to  take  some 
risks  in  order  to  preserve  her  natural  functions. 

In  case  the  patient  commits  her  case  entirely  to  the  hands  of  the  surgeon  to 
use  his  best  judgment,  he  should  act  in  all  cases  as  he  would  do  if  she  were 
his  nearest  relative,  and  try  hard  to  avoid  mutilation. 

CONSERVATIVE   OPERATIONS   OX   THE   OVARY. 

The  removal  of  the  opposite  ovary  in  disease  of  one  side  was  the  habitual 
practice  of  some  of  the  earlier  g^mecologists,  and  still  continues,  as  I  know  by 
e'xperience,  to  be  the  routine  custom  of  men  not  well  trained  in  their  special 
work.  In  so  far  as  the  question  relates  to  unilateral  ovarian  cystoma,  I  have 
given  an  unanswerable  argument  in  the  early  part  of  this  chapter,  elaborated 
from  the  statistics  of  Sir  Spencer  Wells's  one  thousand  cases  of  ovariotomy. 

The  cpiestion  is,  however,  quite  a  different  one  when  one  ovary  is  affected 
with  papilloma,  sarcoma,  or  carcinoma  ;  these  diseases  are  so  frequently  bilateral 
that  there  appears  at  first  sight  to  be  a  marked  liability  on  the  part  of  both 
organs  to  become  affected  independently  of  each  other,  in  which  case  the  second 
ovary,  if  left  behind,  will  be  so  liable  to  require  operation  at  a  later  date  that 
complete  extirpation  of  both  sides  is  the  rule. 

I  can  not,  however,  assent  to  this  theory,  as  yet  unproved,  and  so  have 
adopted  the  following  rules  : 

When  the  opposite  ovary  appears  perfectly  sound  and  normal  in  size,  con- 
sistence, color,  and  outlines,  I  in  all  cases  leave  it  in  a  young  woman. 


174:  COXSERVATLVE    OPERATIONS   ON    THE   TUBES    AND    OVARIES. 

If  it  is  enlarged  and  there  is  reason  to  suspect  disease,  I  remove  it. 

In  a  case  in  which  it  is  extremely  important  to  retain  one  ovary  and  I  am  not 
quite  snre  of  its  condition,  I  excise  a  wedge  of  the  ovarian  tissue  and  harden  and 
examine  it  immediately,  during  the  ojjeration,  under  the  microscope,  and  if  the 
piece  is  found  diseased  I  remove  the  entire  organ  ;  if  no  disease  is  found  I  spare 
the  organ  and  keep  the  patient  under  careful  observation  for  several  yeirs. 

In  a  case  (L.  K.  W.)  of  superficial  paijilloma  of  the  right  ovary  in  a  young 
woman  twenty-seven  years  old,  operated  upon  Feb.  10,  1892,  the  left  ovary, 
which  appeared  sound,  was  left  in ;  she  has  since  married  and  continues  now, 
five  years  after  the  operation,  in  good  health,  without  recurrence,  as  I  have 
assured  myself  by  examination. 

In  another  case  (A.  W.,  50(39,  March  6,  1807)  of  papillomatous  masses  of 
the  right  ovary  sprouting  out  between  enlarged  Graafian  cysts,  I  removed  the 
entire  ovary ;  the  left  ovary  was  sound  except  at  its  outer  pole,  where  there 
were  three  large  Graafian  cy.sts,  without  any  evidence  of  papilloma ;  these  were 
cut  out  and  the  sound  portion  closed  by  a  continuous  catgut  suture. 

In  the  case  of  a  large  fibroma  of  the  right  ovary  (A.  S.  W.,  5061,  March  10, 
1897),  attached  by  a  distinct  pedicle,  2*5  centimeters  long  and  1*5  centimeter 
wide  at  the  inner  pole  of  the  ovary,  my  assistant,  Dr.  Cullen,  exsected  the 
pedicle,  cutting  deeply  down  into  the  ovary,  and  removed  the  mass ;  about 
three  fifths  of  the  ovary  remained  and  the  wound  was  closed  by  a  continuous  cat- 
gut suture. 

The  following  are  the  various  conditions  for  which  conservative  operations 
may  be  practiced  upon  the  ovary  : 

1.  The  ovary  is  not  removed  for  purely  technical  reasons  and  through  adher- 
ence to  a  purely  traditional  style  of  operating — (a)  For  tubal  disease,  (b)  In 
many  cases  of  parovarian  cysts,  (c)  In  extra-uterine  pregnancy,  (d)  In  hys- 
tero-myomectomy. 

2.  Ovarian  adhesions  (peri-ooj^horitis). 

3.  Multiple  Graafian  cysts. 

4.  Single  large  Graafian  cyst. 

5.  Cyst  of  the  corpus  luteum. 

6.  Hematoma. 

7.  Dermoid  cyst. 

8.  Ovarian  cystoma. 

9.  Ovarian  abscess. 

The  conservative  principles  applied  to  the  treatment  of  the  ovary  under 
these  various  conditions  involve  the  puncture  of  some  cysts,  the  exsection  of 
other  cysts  and  sewing  together  the  parts  which  are  left,  and  the  amputation  of 
a  greater  or  lesser  part  of  the  ovary  with  suture  of  the  remainder. 

Whenever  it  is  possible,  the  ovary  with  the  uterine  tube 
should  be  lifted  outside  the  body  and  isolated  by  surround- 
ing it  with  gauze  pads  ;  a  large  cystic  ovary  may  be  emptied  first  by  asj)iration 
and  then  lifted  out,  to  avoid  making  a  large  abdominal  incision.  The  ovarian 
tissue  does  not  usually  bleed  freely,  but  if  there  is  much  oozing  it  may  be  con- 


On  the  right  side  tlie  entire  ovary  has  been  removed  for  papilloma  ;  on  the  left,  two  cystic  Graafian  folli- 
cles have  been  removed  and  the  ovary  sutured  and  left,  as  shown.  The  parts  removed  are  shown  in  the 
lower  part  of  the  figure.     Up.,  March  6,  18y7. 


OVARY    XOT    REMOVED    FOR   TECHXICAL    REASONS. 


175 


whether  in  the  length  or  the  breadth  of 


trolled  readily  by  digital  comjDi-ession  of  the  vessels  at  the  poles.  The  diseased 
ovarian  tissue  may  be  removed  either  with  a  knife  and  forceps  or  with  the  fingers 
when  it  is  friable.  As  the  ovary  is  but  a  small  organ,  and  the  simple  diseases 
treated  conservatively  are  not  liable  to  recur  at  the  site  of  extirpation,  the  dis- 
section should  aim  simply  at  shelling  out  the  affected  portion  with  the  least  pos- 
sible sacrifice  of  good  tissue. 

A  wedge-shaped    excision 
the  ovary   or  at  one  of    the    poles,   is    easier  to    bring    together  by 
suture. 

A  small  needle  threaded  with  a  fine  catgut  suture  is  the 
best  means  of  approximation.  Each  suture  is  passed  well  down  into 
the  tissue,  entering  and  emerging  2  to  3  millimeters  from  the  edges  of  the  cut 
and  tied  tight  enough  to  control  any  hemorrhage  ;  when  all  are  in  place  the 
ovary  is  dropped  back  into  the  pelvis.  If  there  is  but  little  tendency  to  bleed  a 
continuous  suture  may  be  used  with  advantage. 

1.  Ovary  not  Removed  for  Technical  Reasons. — The  ovary  should  never  be  re- 
moved simply  because  the  tube  of  the  same  side  is  taken  out,  and  as  a  matter  of 
convenionce.  The  diseased  tube  can  be  removed  alone  after  releasing  it  from 
its  adhesions  by  cutting  it  off  at  the  uterine  cornu,  or  by  making  an  incision  into 
the  mesosalpinx,  just  under  the  fimbriated  end,  and  then  cutting  or  stripping  it 
loose  along  the  mesosalpinx,  keeping  close  beneath  the  tube,  until  the  detach- 
ment is  complete.  In  this  way  only  small  vessels  are  divided  and  the  bleeding 
is  slight  and  easily  controlled  by  a  few  fine  catgut  ligatures ;  the  layers  of  the 
mesosalpinx  may  then  be  drawn 
together  with  a  continuous  cat- 
gut suture. 

In  all  cases  of  parovarian 
cysts  where  the  ovary  can  be 
traced  by  means  of  the  utero- 
ovarian  ligament  and  clearly 
distinguished  from  the  tumor, 
there  is  no  need  to  sacrifice 
either  the  ovary  or  the  tube  in 
removing  the  cyst. 

Parovarian  cysts  with  clear 
walls  and  of  lesser  size  may  be 
removed  by  incising  the  meso- 
salpinx at  a  point  where  there 
are  the  fewest  vessels,  and  draw- 
ing back  the  peritoneum  on  both 

sides  as  the  cyst  is  shelled  out  from  its  bed  ;  another  plan  of  removal,  useful 
when  the  peritoneum  stretched  out  over  the  cyst  is  redundant,  is  to  make  an  oval 
incision  into  the  peritoneum,  removing  a  sufficiently  large  piece  to  permit  the 
remainder  to  be  drawn  neatly  together  after  the  extirpation. 

In  large  parovarian  cysts  where  the  tube  is  greatly  elongated,  after  tapping 


Fig 


358.— Parovarian  Cyst  in  the  Left  Broad  Ligament 

REMOVED     BY     incising     THE     MESOSALPINX     AND     WITHOUT 
SACRIFICING   EITHER  OVARY  OR   TuBE.      SaN.  NOV  21,  1895. 

Natural  Size. 


176 


CONSERVATIVE    OPERATIONS    ON   THE   TUBES   AND    OVARIES. 


the  cyst  and  bringing  it  outside  and  carefully  distinguishing  the  position  of  the 
tube  and  the  ovary,  the  opening  into  the  mesosalpinx  is  enlarged,  the  cyst  with- 
drawn, bleeding  vessels  secured  and  the  peritoneal  opening  appi*oxiniated,  and 
the  whole  dropped  back  again  minus  the  tumor. 

In  extra-uterine  pregnancy  there  is  no  reason  whatever  for  the  sacrifice  of 
the  ovary  in  removing  a  mutilated  tube ;  Dr.  J.  G.  Clark  has  allowed  the  ovary 
to  remain  without  any  apparent  disadvantage  in  a  case  operated  upon  at  my  clinic. 

In  hystero-myomectomy,  by  tying  off  the  uterine  tube  at  the  uterine  cornu 
instead  of  near  the  pelvic  brim,  the  tube  and  ovary  are  both  pushed  down  into 
the  pelvis  and  out  of  the  way  as  soon  as  the  top  of  the  broad  ligament  is  opened, 
when  the  rest  of  the  enucleation  is  conducted  as  before. 


Fig.  359. — Parovarian  Cyst  extirpated  without  removing  either  Tube  or  Ovary. 

The  cap  of  peritoneum  was  left  on  by  cuttinar  through  it  on  all  sides  and  then  shelling  the  tumor  out  of 
its  cellular  investment.  Note  the  additional  cysts  attaclied  to  the  tumor  on  the  right.  "San.  Nov.  21,  1895. 
Natural  size. 


2.  Adherent  Ovaries. — Ovarian  adhesions  (peri -oophoritis)  may  vary  all  the 
way  from  a  delicate  web  between  the  ovary  and  the  pelvic  wall,  scarcely  appre- 
ciable to  the  touch,  to  a  dense  mass  of  lymph  imbedding  the  ovary  so  com- 
pletely out  of  sight  that  it  appears  to  be  actually  wdthin  the  broad  ligament 
(pseudo-intraligamentary). 

The  lighter  weblike  and  velamentous  adhesions  are  easily  broken  up  with 
the  fingers,  or  by  exposing  the  adhesions  and  using  the  points  of  tlie  scissors  in 
conducting  a  careful  dissection  until  the  ovary  is  freed. 

In  detaching  a  more  firmly  adherent  ovary  the  best  plan  of  procedure  is  to 
try  to  work  the  fingers  in  beneath  it  and  so  secure  a  j)urchase  under  its  free 


EXLARGED    CYSTIC    GRAAFIAN    FOLLICLES.  177 

border  for  rolling  it  on  its  hiliim,  as  an  axis,  from  below  np  toward  the  brim 
of  the  pelvis.  Any  attempt  to  free  it  by  working  in  a  direction  from  above 
downward  will  only  result  in  tearing  the  tissues.  If  the  ovary  hangs  low 
down  in  the  pelvis,  after  freeing  it,  the  ovarian  ligament  should  be  shortened 
by  taking  a  plait  in  it,  so  as  to  lift  the  ovary  closer  up  beside  the  uterus.  I 
have  even  stitched  the  ovary  directly  to  the  uterine  cornu.  After  controlling 
any  hemorrhage  from  the  pelvic  floor  and  walls  the  abdomen  is  closed  without 
a  drain. 

I  would  not  be  understood  to  recommend  opening  the  abdomen  to  release 
any  but  dense  ovarian  adhesions,  for  all  others  which  can  be  broken  up  with 
a  moderate  amount  of  force  may  just  as  well  be  handled  bimanually  and  set 
free  through  the  rectum  and  abdominal  wall. 

This  is  done  by  securing  a  thorough  evacuation  of  the  bowels  and  placing 
the  patient  under  anesthesia ;  the  index  finger  of  one  hand  is  then  carried  well 
above  the  amj)u]la  behind  the  uterus  by  pushing  the  uterus  a  little  back  into 
retroflexion  ^nth  the  other  hand ;  then  the  index  finger,  passing  along  toward 
the  cornu,  readily  distinguishes  the  prominent  utero-ovarian  ligament,  and  by 
tracing  this  out  toward  the  jDelvic  wall  the  ovary  is  found. 

After  determining  its  size  and  outlining  any  irregularities  of  its  surface,  the 
next  effort  made  is  to  test  its  mobility,  and  this  is  done,  not  by  pushing  it  up  as 
a  whole,  but  by  introducing  the  finger,  or  if  need  be  two  fingers,  under  its  lower 
border  and  lifting  it ;  if  it  is  free,  it  will  go  up  easily,  rotating  on  its  hilum  as  an 
axis ;  if  it  is  adherent,  the  adhesions  will  be  felt  giving  way  and  snapping  one 
after  anotlier  as  the  pressure  is  increased  until  the  whole  surface  is  freed.  The 
greatest  difliculty  will  be  found  in  completely  freeing  the  pole  next  to  the  pelvic 
wall ;  after  the  ovary  is  entirely  free,  the  finger  can  be  carried  around  it  on 
every  side,  above  and  below  and  around  both  poles,  and  it  responds  readily  to 
every  touch. 

3.  Multiple  and  Small  Graafian  Cysts. — It  is  not  yet  decided  whether  any 
clinical  symptoms  arise  from  the  cystic  folHcles  often  seen,  from  the  size  of 
a  pea  to  that  of  a  cherry.  It  has  been  my  habit,  as  well  as  that  of  many  other 
operators,  to  bring  out  the  ovary  and  puncture  these  cysts  with  a  knife  point  or 
a  needle,  and  to  empty  them  by  pressure.  P.  Miiller  and  Pozzi  use  the  thermo- 
cautery in  opening  them,  to  prevent  reclosure.  Until  we  know  just  how  far  an 
aggregation  of  cystic  follicles  may  be  a  departure  from  the  normal,  we  shall  not 
be  in  a  position  to  decide  this  important  question.  One  thing,  however,  is  quite 
certain  for  the  present,  and  that  is  that  they  never  of  themselves  justify  removal 
of  an  ovary  or  even  of  a  piece  of  an  ovary. 

4.  Enlarged  Cystic  Graafian  Follicles. — Graafian  follicle  cysts  form  a  definite 
group  of  tumors  of  the  ovary,  and  are,  as  indicated  in  the  name,  simply  enlarge- 
ments of  structures  which  normally  remain  small  and  rupture  or  disappear. 

Sucli  cysts  are  single  or  multiple  and  vary  in  diameter  from  0  to  8  milli- 
meters to  0  or  8  centimeters  or  even  more. 

The  smaller  cysts  can  only  be  reckoned  as  pathological  when  they  occur  in 
large  numbers  in  an  enlarged  ovary,  as  shown  in  Fig.  300,  and  nnist  be  care- 


178 


CONSERVATIVE    OPERATIONS    ON    THE   TUBES    AND    OVARIES. 


fully  distinguished  from  the  few  small  cysts  normally  found  in  ovaries  which 

are  not  enlarged ;  they  appear  as  numerous  pealike  projections  over  the  surface 

of  a  large  ovoid  ovary  with  a  dense  coat. 

The  single  cysts  increase  to  the  size  of  a  walnut  or  an  orange,  occupying  a 

part  of  the  ovary  with  translucent  walls,  easily  ruptured. 

Pathologically  these  are  nothing  more  than  dilated  cystic  follicles  ;  if  they 

are  adherent  in  the  pelvis  their  surface,  instead  of  being  smooth,  is  roughened 

by  the  attachments. 

The  walls,  varying 
in  thickness  from  1*5 
to  2  or  3  millimeters, 
are  thinnest  at  the 
most  prominent  part. 
The  fluid  within  re- 
sembles serum  or  clear 
water,  or  it  may  be 
made  turbid  by  hem- 
orrhage. It  contains 
desquamated  and  fatty 
epithelial  cells.  Ova 
are  often  found  with- 
in demonstrating  their 
origin. 

The  cyst  wall  ex- 
hibits   the    layers    of 
the    Graafian    follicle 
with  a  single  layer  of 
Round  hyaline  masses  correspond  to  de- 


FiG.  360. — Hypertrophy  of  the  Ovary,  with  Cystic  Degeneration. 

Over  twenty  follicles  are  visible  on  the  surface,  projecting  from  beneath 
the  thick  capsule.     Path.  No.  282. 


cuboidal  or  flat  epithelium  within, 
generate  epithelial  cells. 

I  have  had  one  case  in  which  a  dilated  Graafian  follicle  and  a  cystic  corpus 
luteum  existed  side  by  side  in  the  same  ovary.  The  j^artition  wall  broke  down 
and  the  two  coalesced,  forming  a  single  cyst  with  the  characteristics  of  each  in 
different  places. 

The  symptoms  produced  are  generally  more  or  less  constant  discomfort  or 
pain  on  the  side  on  which  the  tumor  is  situated,  increasing  at  the  menstrual 
period.  The  physical  signs  presented  by  such  cysts  are  usually  definite  enough 
to  enable  the  examiner  to  make  a  correct  diagnosis. 

Such  follicles  may  rupture  spontaneously  through  the  increasing  tension  of 
the  thin  walls  and  the  patient  experiences  a  sudden  relief,  or  they  are  often 
ruptured  accidentally,  as  I  have  seen,  in  making  a  bimanual  examination.  In 
several  cases,  upon  opening  the  abdomen  at  once,  I  have  found  fi-om  20  to 
50  cubic  centimeters  of  blood-tinged  serum  in  the  pelvis  with  the  torn  edges 
of  the  cyst  floating  in  it. 

If  a  positive  diagnosis  could  be  made  in  every  case  it  would  never  be 
necessary  to  open  the  abdomen  for  the  sole  purpose  of  treating  these  cysts,  for 


EXLARGED    CYSTIC    GRAAFIAN    FOLLICLES. 


179 


the  plan  of  rupturing  tliera  bj  pressure  made  by  a  finger  in  the  vagina  or 
rectum  would  be  perfectly  safe,  and  probably  in  most  instances  just  as  efficient 
in  curing  the  affection  as  an  extirpation  by  celiotomy. 

While  they  can  be  recognized  with  certainty  in  most  cases  by  a  well-trained 
touch,  they  may  be  confused  with  a  corpus  luteum  cyst,  an  ovarian  or  tubal 
abscess,  or  encysted  pelvic  perito- 
nitis, or  a  hydrosalpinx. 

The  differential  points  are 
these :  the  Graafian  cyst  has  usu- 
ally such  thin,  delicate  walls  that 
they  seem  almost  ready  to  rupture 
on  making  the  gentlest  pressure ; 
it  is  more  or  less  spherical  in  out- 
line, and  at  its  base  connected  with 
the  ovary,  and  as  a  rule  it  is  not 
adherent.  Abscess  cases  and  en- 
cysted peritonitis  show  evidences 
of  surrounding  inflammation  in  the 
hardening  of  the  incasing  tissues  ; 
the  hydrosalpinx  is  elongated  and 
not  so  circumscribed.  Wherever 
there  is  any  doubt  in  the  diagnosis, 
the  safe  rule  is  not  to  rupture  the 
cyst,  but  to  take  it  out  by  the  ab- 
domen or  by  a  vaginal  incision. 

The  cyst  may  be  deliberately 
ruptured  by  grasping  it  between 
the  fingers  through  the  abdomen 

and  rectum  and  gradually  increasing  the  pressure  until  it  breaks  suddenly,  and 
in  a  moment  all  trace  of  the  tumor  is  gone.  I  have  twice  opened  the  abdomen 
for  other  causes  within  two  or  three  days  after  the  unintentional  rupture  of  one 
of  these  cysts  in  the  course  of  a  preliminary  examination,  and  found  but  a  few 
cubic  centimeters  of  blood,  serum,  and  a  flaccid  collapsed  cyst  with  a  wide  rent 
in  its  wall. 

If  the  sac  does  not  yield  to  a  moderately  firm  pressure,  the  effort  should  be 
abandoned  and  the  cyst  tajjped  -through  the  vagina.  Before  tapping,  the  vagina 
must  be  cleansed  thoroughly  with  soap  and  water ;  then  a  long  trocar  and  can- 
nula attached  to  an  aspirator  is  introduced  guided  by  the  finger,  which  rests  on 
the  tumor  at  the  vault  of  the  vagina ;  an  assistant,  by  making  pressure  above, 
brings  the  cyst  firmly  down  onto  the  vaginal  finger,  while  the  operator  pushes 
the  trocar  and  cannula  into  the  now  prominent  convex  surface  close  to  and 
a  little  behind  the  cervix,  in  a  direction  upward  and  slightly  backward. 
The  trocar  is  withdrawn  and  the  fluid  evacuated  through  the  cannula. 
After  evacuation  the  cannula  is  withdrawn  and  the  vagina  loosely  packed 
with  iodoform  gauze.     There  is  no  reaction  following  so  slight  an  operation. 


Fig.  36L — Hemorrhagic  Corpus  Luteum  Cyst  {€)  and 
Cystic  Graafian  Follicle  {G)  in  the  Same  Ovary. 

The  cysts  are  buckled  toorether  and  were  developed 
from  the  outer  extremity  of  the  ovary  ( O)  on  both  sides 
of  the  tubo-ovarian  fimbria.  The  tube  is  held  rigid, 
stretched  out  in  tlie  sulcus  between  the  cysts.  May  16, 
1896.    Natural  size. 


180 


CONSERVATIVE    OPERATIONS    ON"   THE   TUBES   AND   OVARIES. 


When  such  a  cyst  is  ruptured  or  evacuated  in  this  way  it  does  not,  as  a  rule, 
refill. 

After  rupture  the  patient  should  be  kept  in  bed  two  or  three  days  and  have 
the  bowels  freely  opened. 

The  operation  for  the  removal  of  the  cyst  by  celiotomy  is  a  simple  one.  If 
it  is  small  and  can  be  easily  brought  out  of  the  incision  without  rupture,  this  may 
be  done,  but  if  it  is  large  it  is  better  to  tap  the  cyst  and  empty  it  and  draw  it  out 
in  a  collapsed  condition,  rather  than  to  enlarge  a  small  incision.  Laying  the 
ovary  with  the  cyst  on  a  small  pad,  the  cyst  is  then  exsected,  and  as  it  usually 
lies  attached  to  the  superficial  free  portion  of  the  ovary,  this  again  need  not  be 
cut  into  deeply. 

Sometimes  it  is  attached  to  one  of  the  poles  or  to  the  free  border,  and  is 
almost  pedunculate  ;  in  this  case,  an  oval  incision  is  made  around  its  base  and  a 
careful  dissection  sufiices  to  peel  it  out  of  its  bed,  and  the  wound  in  the  ovarian 
tissue  is  then  closed  with  a  few  interrupted  catgut  sutures,  or  with  a  continuous 
suture,  if  the  wound  is  a  long  one. 

Multiple  large  cysts,  either  connected  or  isolated,  should  be  treated  in  the 
same  way. 

5.  Cysts  of  the  Corpus  Luteum. — These  are  corpora  lutea  which  have  not 
ruptured  and  which  have  reached  abnormal  dimensions.     The  average  size  is 

that  of  a  walnut,  but  they  may  reach 
6  centimeters  or  more  in  diameter.  If 
small  they  are  seen  as  cysts  springing 
from  the  ovary,  but  if  large  they  may 
occupy  the  greater  part  of  the  ovarian 
tissue.  Their  walls  may  be  gray,  bright 
red,  bluish  red,  or  almost  black,  but 
shining  through  the  peritoneal  cover- 
ing, usually  there  is  a  yellowish  red  or 
golden  yellow  tissue  similar  to  that  seen 
in  a  typical  corpus  luteum.  Beneath 
the  peritoneal  covering  numorous  fine 
branching  blood-vessels  can  be  seen. 
The  cyst  walls  vary  from  1  to  2  milli- 
meters in  thickness.  The  inner  surface 
is  covered  by  a  reddish  yellow  mem- 
brane to  which  a  few  clots  may  be  at- 
tached. The  cavity  is  partially  or  com- 
pletely filled  with  blood,  which  may 
have  undergone  retrogressive  changes, 
and  accordingly  be  of  a  dark  chocolate 
or  inky  black  color.  These  cysts  are  but  loosely  connected  with  the  tissue  of  the 
ovary,  and  are  sometimes  even  shelled  out  accidentally  while  handling  the  ovary. 
Histologically  the  cyst  walls  are  composed  of  ovarian  stroma,  which  may 
contain  ova,  Graafian  follicles,  or  corpora  fibrosa.     The  inner  surface  is  lined 


Fig.  362. — Cy.st  of  the  Corpus  Luteua 

The  uterine  tube  lies  on  the  cyst  above 
173.     Natural  size. 


No. 


j 


DERMOID    CYSTS    OF   THE    OVARY. 


181 


by  several  layers  of  corpora  lutea  cells,  some  of  wliich  may  be  swollen  and  filled 
with  brown  granular  pigment,  or  present  a  vacuolated  appearance.  Passing  in- 
ward from  the  ovarian  stroma  are  spindle-shaped  cells,  which  divide  the  corpora 
lutea  cells  into  rows.  Numerous  new-formed  blood  capillaries  may  accompany 
these  spindle-shaped  cells.  The  cyst 
cavity  contains  red  blood-corpuscles ; 
degenerate  cells,  polynuelear  leuco- 
cytes, and  granular  material  may 
also  be  present. 

These  cysts  do  not  differ  in  any 
way  cHnically  from  the  Graafian 
cysts  just  described,  unless  it  be 
that  the  wall  of  the  cyst  is  some- 
times thicker  and  the  contents  jelly- 
like and  discolored  with  blood. 

The  operation  is  in  all  resjjects 
similar  to  that  described  above. 

The  figures  in  the  text  show  well 
how  easily  such  a  cyst  may  be  re- 
moved, often  leaving  the  ovary  al- 
most intact. 

G.  Hematoma  of  the  Ovary. — The 
surgical  treatment  of  hematoma  will 
vary  with  the  extent  of  the  disease. 

From  our  present  standpoint  the  hematoma  must  be  reckoned  among  the  be- 
nign tumors,  and  the  conservative  course  of  treatment  is  a  proper  one  whenever 
it  can  be  of  any  use.  When  the  entire  ovary  appears  to  be  taken  up  by  a  large 
hematoma,  and  no  sound  ovarian  tissue  can  be  found  about  its  hilum,  the  better 
plan  will  be  to  extirpate  the  ovary.  When,  on  the  other  hand,  but  a  portion  of 
the  ovary  is  involved,  the  affected  part  should  be  cut  away  and  the  sound  por- 
tion left.  This  will  often  demand  a  more  extensive  dissection  of  the  tissue  than 
in  cystic  disease,  on  account  of  the  more  intimate  relation  of  the  hematoma  to 
the  ovary ;  but  the  suturing  and  the  rest  of  the  treatment  is  the  same. 

7.  Dermoid  Cysts  of  the  Ovary. — Quite  another  field  for  conservatism  is  opened 
up  in  the  treatment  of  dermoid  tumors  and  ovarian  cystomata. 

The  first  case  operated  upon  in  this  way  was  by  C.  Schnkler  {Zeitschr.  f. 
Geb.  u.  Gf/n.,  Bd.  xi,  p.  360).  The  patient,  twenty-five  years  old,  had  had  one 
child,  which  had  died,  and  she  was  intensely  anxious  for  another. 

Celiotomy  was  performed  Nov.  30,  1882.  The  tumor  on  the  right  side  was 
of  a  mixed  nature — both  cystoma  and  dermoid — and  was  so  developed  as  to  leave 
intact  and  sound  a  considerable  part  of  the  ovary,  from  which  the  tumor  was  ex- 
cised and  the  wound  closed  by  suture.  The  left  ovary  was  about  three  times 
enlarged  l)y  a  small  dermoid  cyst,  which  was  removed  by  a  wedge-shaped  ex- 
cision, and  the  surfaces  united  by  fourteen  sutures.  Examination  over  a  year 
later  showed  an  exudate  behind  the  uterus. 


Fig.  363. — Pedixculate  Corpus  Liteim  Cyst  of  the 
Left  Ovary,  in  which  the  Timor  is  attached 
TO  the  Ovary'  by'  a  Broad  Pedicle  of  Ovarian 
Tissue. 

Upon  removal  of  the  cyst,  sound  ovarian  tissue  is 
left.     Jan.  4,  1803.     Natural  size. 


182  COXSERVATIVE    OPERATIONS    ON"   THE   TUBES    AND    OVARIES. 

This  initial  experiment  has  been  most  successfully  repeated  bj  F.  Matthaei 
{Zeitschr.f.  Geh.  u.  Gf/n.,  Bd.  xx^ii,  1895,  p.  351). 

In  four  cases  of  dermoid  cysts  involving  both  ovaries,  the  tumor  on  one  side 
being  large  and  on  the  other  side  small — "  about  the  size  of  a  walnut " — the 
large  tumor  was  extirpated  with  tlie  ovary,  while  the  small  one  was  exsected 
from  the  sound  ovarian  tissue,  and  the  wound  sewed  up  with  a  continuous  cat- 
gut suture.  In  each  one  of  these  instances  the  patient  either  became  pregnant 
or  bore  a  living  child  within  two  years  after  the  operation. 

8.  Ovarian  Cystoma. — While  an  ovarian  cystoma  commonly  involves  the  en- 
tire ovary  in  such  a  manner  as  to  prevent  the  isolation  of  any  definite  portion 
of  normal  ovarian  tissue,  in  exceptional  cases  a  part,  and  it  may  be  even  the 
greater  part,  of  the  ovary  may  be  found  unaffected  by  cystic  degeneration  at 
the  base  of  the  tumor ;  the  best  guide  to  discover  such  a  portion  of  sound  tissue 
is  the  utero-ovarian  ligament,  which  can  always  be  found.  When  it  has  been 
necessary  to  remove  the  other  ovary,  or  when  the  opposite  tube  or  ovary  is 
extensively  diseased,  it  will  be  justifiable  to  remove  the  cystic  portion  alone  and 
to  leave  behind  that  portion  of  the  ovary  which  macroscopically  appears  to  be 
sound.  The  figure  in  the  text  shows  a  case  (G.  H.  K.,  4224)  operated  upon, 
March  21,  1896,  for  multilocular  ovarian  cystoma  with  twisted  pedicle.  Had  it 
been  important  to  preserve  this  ovary,  an  examination  of  the  drawing  will  show 
how  readily  the  greater  part  of  it  could  have  been  left  after  removing  the  tumor. 

In  cases  of  ovarian  sarcoma  resembling  an  ordinary  cystoma,  the  second 
ovary,  if  it  has  presented  any  suspicious  appearances,  ought  to  be  removed  as 
soon  as  the  diagnosis  is  made  by  the  microscopic  examination. 

In  an  unfortunate  case  of  Hegar's  {Verhcmd.  d.  Deutsch.  GeseUsch.f.  Gyn., 
1892,  p.  255)  a  right-sided  cystoma  was  removed,  and  a  left  ovary  which  looked 
suspicious  was  left ;  the  microscopic  examination  showed  that  the  tumor  was 
sarcomatous.  The  woman  went  home,  became  pregnant,  and  bore  a  miserable 
deformed  child,  and  returned  to  the  clinic  with  a  tumor  of  the  opposite  ovary, 
which  was  inoperable,  and  from  which  she  died. 

9.  Ovarian  Abscess. — In  some  cases  of  ovarian  abscess  the  ovary  may  be 
saved  by  a  carefully  applied  conservatism.  In  the  rai-e  instances  in  which  the 
abscess  is  located  down  in  the  center  of  the  ovary  and  surrounded  by  a  thick 
capsule  the  ovary  may  be  brought  up.  laid  freely  open,  the  pus  evacuated,  and 
the  lining  membrane  of  the  cavity  scraped  or  dissected  out,  after  which  the 
ovary  may  be  closed  by  suture  and  dropped  again  into  the  pelvis. 

While  it  is  not  my  intention  to  speak  here  in  detail  of  the  conservative  treat- 
ment of  pelvic  abscesses  (see  Chapter  XXYII),  it  is  important  to  refer  to  those 
cases  of  pelvic  abscess  involving  both  ovary  and  tube  which  have  recovered  by 
drainage  through  the  vault  of  the  vagina  without  the  extirpation  of  either  ovary 
or  tube.  In  three  instances  of  this  kind  in  my  practice  pregnancy  has  occurred 
after  the  healing  of  the  abscess. 


C02irSERVATIVE    OPERATlOJfS   OX   THE    UTERINE   TUBES. 


183 


CONSERVATIVE  OPERATIONS  ON  THE  UTERINE  TUBES. 

Although  the  tube  is  a  more  deHcate  structure  than  the  ovarj,  and  its 
function  as  a  carrier  of  the  ovary  is  more  easily  disturbed  than  is  that 
of  the  maturation  and  discharge  of  the  ova  from  the  ovary,  it  is,  how- 
ever, marvelously  amenable  to  conserv-  .  ative  treatment  in  a  variety 
of  affections.  The  following  are  the  /,  commonest  operations  which 
may    be    practiced    upon   the   uterine      11  Mk       tubes 


f IG.  365. — VELAilENToL'S    AdUESIUX    OF    THE    Kn.lir     LlKi;! 


Itself  and  to  the  Uterine  Cobnu. 


April  1,  Isyj.      Natural  Smze. 


1.  The  release  of  adherent  tubes. 

2.  The  opening  or  resection  of  closed  tubes. 

3.  The  emptying,  cleansing,  and  sterilization  of  inflamed  tubes. 

4.  Tlie  amputation  of  diseased  tubes. 

5.  The  exsection  of  diseased  or  of  strictured  tubes, 
fi.  The  drainage  of  tubal  abscesses. 

7.  Preservation  of  the  tube  in  extra-uterine  pregnancy. 
1.  Adherent  Tubes. — Adliesions  binding  the  tubes  down  in  the  pelvis  may 
often  be  released  l)y  running  the  fingers  down  under  tlie  tube  and  breaking 
them  up  one  after  another,  or  by  exposing  the  uterine  end  of  the  tube  and 
making  traction  upon  it,  and  so  tracing  the  tube  down  toward  the  pelvic  floor. 
Adhesions  which  can  not  be  broken  easily  with  the  fingers  shouki  be  exposed 
53 


184 


CONSERVATIVE    OPEEATIONS    ON   THE   TUBES    AND    OVARIES. 


and  divided  with  the  scissors ;  too  great  traction  or  too  rough  manipulation 
must  not  be  made  as  it  is  Hable  to  rupture  the  tube. 

It  is  not  only  important  to  set  free  an  imprisoned  tube  in  this  way,  but 
to  divide  every  adhesion  found  in  any  way  connected  with  its  peritoneal 
surface. 

To  set  a  tube  free  from  its  pelvic  wall  adhesions  and  leave  it  kinked  is  to  risk 
an  extra-uterine  pregnancy  afterward.  The  figure  in  the  text  shows  an  example 
of  a  tube  flexed  at  an  acute  angle  by  an  adhesion  upon  itself,  stretching  from  the 
ampulla  to  its  uterine  end ;  the  simple  division  of  such  band  of  adhesions  sets 
the  tube  free  and  restores  its  normal  mobility. 

The  tubo-ovarian  fimbria  is  one  of  the  most  important  parts  of  the  tube, 
because  it  is  the  hinge  or  arm  by  which  the  tube  is  enabled  to  apply  itself  to  all 
parts  of  the  ovary  and  so  to  take  up  the  discharged  ova,  which  are  then  trans- 
mitted to  the  uterus. 

I  find  three  kinds  of  adhesions  affecting  this  important  tubal  structure,  two 
of  which  are  figured.  One  is  a  simple  shortening  due  to  adhesions,  wliich 
restricts  the  area  to  which  the  tube  may  apply  itself  to  a  short  radius  about  the 


Fig.  366. — Angular  Attachment  of  the  Left  Uterine  Tube  to  the  Coknu  of  the  Uterus. 

Dec.  16,  1896. 


outer  pole ;  in  another  the  tube  is  contracted  down  to  the  ovary  by  an  oblitera- 
tion of  the  outer  portion  of  the  mesosalpinx,  so  that  it  lies  with  its  orifice 
directed  away  from  the  ovary ;  in  the  third  the  tube  is  flexed  about  the  ovary 
with  its  lumen  still  open  and  turned  toward  one  small  area,  to  which  it  may  be 
closely  applied. 

The  treatment  of  these  adhesions  simply  requires  a  careful  dissection  with  a 


EMPTYING,    CLEANSING,    AND    STERILIZATION    OF   INFLAMED   TUBES.  185 

scalpel,  detaching  the  tube  from  the  ovary  until  the  mesosalpinx  and  the  tubo- 
ovarian  fimbria  are  restored  to  their  normal  length. 

2.  Closed  Tubes. — When  adhesions  form  about  the  fimbriated  extremity  of 
the  uterine  tube  on  its  peritoneal  surface  the  tendency  of  the  contracting 
lymph  is  to  roll  in  the  mucous  surfaces,  and  so  to  gradually  obliterate  the 


Fio.  367. — Adhesions  of  the  Outer  Free  Extremities  of  both  Uterine  Tubes  to  the  Ovaries. 

Showing  the  method  of  dividing  the  adhesions  with  the  scalpel  and  so  freeing  the  tubes.  On  the  right 
side  the  tuBe  is  attached  in  such  a  manner  that  its  open  extremity  looks  away  from  the  ovary ;  on  the  left 
side  the  tube  is  fastened  down  with  its  orifice  facing  the  ovary.     Feb.  1, 1896.    %  natural  size. 


lumen  of  the  tube.  In  an  earlier  form  these  adhesions  may  be  seen  just 
back  of  the  fimbriae  surrounding  the  tube  like  a  collar,  forming  a  white 
fibrous  band  encircling  it  from  2  to  4  millimeters  in  diameter ;  in  a  more 
advanced  form  the  lumen  may  be  closed  down  to  a  little  orifice,  out  of  which 
pouts  one  or  more  congested  fimbriae ;  in  its  most  advanced  form  the  orifice 
is  completely  obliterated  and  replaced  by  a  depressed  scar  radiating  out  over 
the  knobbed  end.  This  collar  may  be  divided  in  several  places,  releasing  the 
fimbriae. 

The  closed  tube  may  be  opened  best  by  cutting  through  the  scar  and  up 
along  its  dorsum  for  from  1  to  1^  centimeters,  and  so  laying  bare  the  lumen  of 
the  tube  and  forming  a  new  orifice.  The  mucous  lining  should  then  be  drawn 
out  and  attached  to  the  peritoneum  by  fine  catgut  sutures. 

Any  contents  of  the  tube  must  be  carefully  taken  up  on  gauze,  and  if  they 
are  other  than  a  clear  limpid  fluid,  the  tube  must  be  washed  out  as  described  in 
the  following  section. 

'1  Emptying",  Cleansing,  and  Sterilization  of  Inflamed  Tubes. — Sometimes  a 
catarrhal  ov  a  parenchymatous  salpingitis  is  found  with  a  greatly  congested  and 
thickened  tube,  whose  orifice  is  open,  and  a  little  milking  easily  forces  out  a 
drop  or  so  of  bloody  serum  or  of  mixed  blood  and  pus. 


186  CONSERVATIVE    OPERATIOXS    ON   THE   TUBES    AND    OVARIES. 

Under  such  circumstances  the  decision  will  often  be  difficult  whether  it  will 
be  safe  or  not  to  attempt  to  save  the  tube.  The  surgeon  will  be  guided  princi- 
pally by  the  intensity  of  the  local  reaction  already  produced  on  tlie  j)elvic  peri- 
toneum by  the  infection,  as  well  as  by  the  character  and  abundance  of  the  cocci 
found  by  an  immediate  microscopic  examination,  coupled  with  such  facts  as 
have  been  elucidated  from  the  history.  Associated  with  these  data,  due  weight 
must  be  given  to  the  urgency  of  saving  the  tube  in  the  particular  case  in  hand. 
This  urgency  will  naturally  be  greater  if  the  other  tube  must  be  sacrificed,  as  is 
often  the  case  when  the  grade  of  the  inflammatory  infection  varies  on  the  two 
sides ;  the  age  of  the  woman  and  the  number  of  children  she  has,  as  well  as  her 
condition  in  life,  must  also  be  considered.  The  most  favorable  cases  are  those 
where  no  organisms  are  found  at  all,  or  where  the  gonococci  appear  alone. 

To  cleanse  a  tube,  it  is  lifted  out  of  the  abdomen,  if  possible,  and  laid  on  a 
gauze  pad  and  gently  squeezed  empty  a  few  times  by  stroking  it  from  the  uter- 
ine toward  the  fimbriated  end ;  the  fluid  discharged  should  be  used  for  cover- 
slip  and  culture  experiments.  The  tube  is  then  washed  out  with  normal  salt 
solution  by  a  syringe  attached  to  a  fine  silver  cannula  with  a  rounded  end  per- 
forated with  holes ;  the  end  of  the  syringe  is  introduced  as  far  as  it  will  go 
easily,  and  the  fluid  forced  in  and  collected  as  it  flows  out  from  the  fimbriated 
end. 

After  washing  it  clean  in  this  way  the  tubal  mucosa  is  sterilized  with  a 
1-5,000  bichloride  of  mercury  solution,  emptied,  wiped  dry,  and  dropped  back 
into  the  pelvis. 

4.  Amputation  of  Diseased  Tubes.  —  If  the  outer  extremity  only  of  a  tube  is 
diseased,  an  amjjutation  may  be  done  so  as  to  remove  the  disease  and  leave 
whatever  part  is  sound. 

In  this  way  the  end  only  may  be  cut  off,  or  half,  or  even  the  whole  ampulla 
removed.  It  is  of  manifest  advantage  to  leave,  if  possible,  a  little  of  the  distal 
end  of  the  tube  in  order  to  secure  an  open  orifice  to  take  up  any  ova  which 
might  by  chance  fall  into  it  or  be  drawn  into  it  by  the  pelvic  current  which  sets 
toward  the  orifices  of  patent  tubes. 

C.  C.  Burrows  has  practiced  amputation  in  cases  of  pyosalpinx  in  five  in- 
stances, as  recommended  by  Polk  {Trans.  A^ner.  Gyn.  Soc,  vol.  xviii,  p.  182). 
He  says  that  in  some  cases  there  is  a  healthy  patulous  portion  of  the  tube  next 
to  the  uterus,  which  is  shut  off  from  the  outer  diseased  end,  and  "  in  such  cases 
where  the  ovary  is  healthy  and  the  fimbriated  end  of  the  pus  tube  is  not  adher- 
ent to  it,"  he  has  amputated  the  tube  at  the  outer  end  of  the  healthy  portion, 
washed  it  out,  slit  it  uj)  a  short  distance,  and  united  its  serous  and  mucous  coats 
by  fine  catgut  sutures,  forming  an  artificial  abdominal  ostium.  Five  cases  treated 
in  this  way  made  perfectly  good  recoveries. 

When  the  whole  ampulla  is  removed,  then  even  the  stump  of  the  isthmus 
may  be  serviceable  with  its  small  orifice. 

In  amputating  a  tube,  a  ligature  is  never  thrown  about  its  lumen,  but  it  is 
simply  cut  off  with  a  scalpel,  the  bleeding  checked,  and  the  permanency  of  the 
opening  secured  by  uniting  the  mucous  and  peritoneal  surfaces  by  suture. 


EXTKA-UTERIXE    PREGXAXCY.  187 

5.  Exsection  of  Diseased  or  Strictured  Tubes. — In  nodular  disease  of  the  tubes, 
or  in  the  case  of  a  stricture  of  the  tu])e,  or  in  event  of  the  entire  division 
of  tlie  tube  into  two  parts,  the  diseased  portion  may  be  excised  and  the  ends 
brought  together  by  an  end-to-end  anastomosis  (salpingo-salpingostomy). 

If  there  are  several  nodes  feeling  like  little  hard,  ovoid  lumps  in  the  tube, 
often  of  a  yellowish  color,  it  will  be  better  not  to  try  to  save  the  tube,  except  for 
stringent  reasons,  as  this  is  one  of  the  forms  in  which  tuberculosis  of  the  tube  is 
often  locahzed. 

After  cutting  out  the  disease,  the  ends  of  the  tube  may  he  united  by  fine  cat- 
gut sutures  penetrating  the  peritoneal  and  muscular  coats  and  introduced  at  in- 
tervals of  about  2  millimeters. 

In  order  to  graft  the  isthmus  on  to  the  ampulla,  it  must  be  slit  open  on  its 
dorsum  to  make  a  lumen  corresponding  in  size  to  that  of  the  ampulla  to  which  it 
is  to  be  attached. 

6.  Drainage  of  Tubal  Abscesses. — The  treatment  of  tubal  abscesses  (pyosalpinx) 
as  ordinarily  found  walled  off  by  a  blanket  of  adhesions  from  the  rest  of  the 
peritoneal  cavity,  is  fully  discussed  in  the  chapter  on  pelvic  abscess.  I  desire 
here  to  speak  more  particularly  of  the  treatment  of  those  tubes  full  of  pus 
which  are  found  free,  or  comparatively  free,  in  the  pelvis  and  without  any  at- 
tachments to  the  vaginal  vault. 

When  one  tube  is  diseased  in  this  way  and  the  other  is  in  better  condition,  I 
would  sacrifice  the  tube  containing  pus  and  direct  my  efforts  toward  saving  the 
one  least  affected.  When  both  tubes  are  distended  by  pus,  or  when  the  tulje 
containing  pus  is  the  only  one  remaining,  and  conservatism  is  desirable,  the  fol- 
lowing plan  may  be  tried  :  After  bringing  the  tubes  up  onto  a  23iece  of  gauze 
and  opening  them  on  the  dorsum  at  the  outer  end  and  washing  them  out,  they 
are  then  dropped  back  into  the  pelvis  and  a  free  opening  made  in  the  vaginal 
vault  by  puncturing  it  with  scissors  introduced  into  the  vagina  by  an  assistant 
and  pushed  through  into  the  pelvic  cavity  under  the  guidance  of  the  operator's 
hand  within  the  abdomen ;  the  opening  thus  made  beliind  the  cervix  is  then 
enlarged  with  a  dilator,  and  an  iodoform  gauze  pack  introduced  so  as  to  fill 
the  lower  part  of  the  pelvis  loosely  and  drain  into  the  vagina.  The  ends  of  the 
tubes  are  loosely  imbedded  between  the  folds  of  this  pack ;  it  is  removed  in  five 
to  seven  days  and  the  opening  allowed  to  close. 

The  figures  in  the  text  are  taken  directly  from  a  case  treated  successfully  in 
this  way. 

7.  Extra-uterine  Pregnancy. — The  radical  exsective  method  of  treating  extra- 
uterine pregnancy  can  only  be  justified  when  the  identity  of  the  tube  is  so  dis- 
torted or  when  the  tulje  is  so  far  destroyed  that  its  regeneration  is  impossil^le. 
In  many  cases  where  the  hemorrhage  has  long  since  stopped,  and  where  there 
is  a  tubal  abortion  with  an  intact  tube  or  a  small  rent,  there  is  no  reason  why 
the  tube  should  not  be  freed  from  its  adhesions,  cleansed  as  far  as  possible  of 
all  clots,  the  rent  sutured,  and  the  tube,  together  with  its  ovary,  preserved. 

Particular  care  must  be  taken  to  make  sure  that  the  lumen  of  such  a  tube 
will  admit  a  probe  all  the  way  through  to  the  uterus. 


188 


CONSERVATIVE    OPERATIOXS    ON   THE   TUBES    AND    OVARIES. 


PREGNANCY  FOLI.OWING  CONSERVATISM. 

Out  of  a  series  of  eigbtj  cases  treated  conservatively  by  Dr.  W.  M.  Polk, 
and  most  of  them  seen  at  intervals  varying  from  six  months  to  two  years  after 
the  operation,  all  but  seven  gave  excellent  results,  and  four  out  of  the 
eighty    bore   children   (iY.  Y.  Jour.  Gyn.  and  Ohs..,  Aug.,  1893). 

A.  Martin,  in  a  series  of  forty-five  cases — twenty-one  of  resection  of  the  ova- 
ries and  twenty-four  of  operations  upon  the  tubes — lost  two,  one  in  each  group ; 
and  of  the  twenty  women  surviving  the  ovarian  conservative  operations,  five 
became   pregnant. 

One  of  his  patients,  operated  u]:>on  in  Oct.,  1888,  had  the  right  adnexa  re- 
moved and  the  left  tube  resected  for  hydrosalpinx,  became  pregnant,  and 
aborted  in  April,  1889. 

Pregnancy  after  an  Operation  leaving  One  Tube  and 
the  Opposite  Ovary. — Pregnancy  can  only  take  place  in  the  presence 
of  a  delicate  adjustment  of  the  pelvic  organs  in  their  mutual  relations,  and 
therefore  furnishes   perhaps  the  best  test  of  the  success  of   any  conservative 


Fig.  3(38. — Conservati\l  f'l'hicAiioN    i 


The  right  tube,  rigid  and  closed  with  a  bulbous  end,  was  removed.     The  left  ovary,  converted  into  a  large 
hematoma,  was  also  removed.     Mrs.  B.     Oj-).,  March  2, 1895. 

operation.  It  must  be  borne  in  mind,  however,  that  there  are  other  causes 
than  the  disease  of  the  adnexa  which  conspire  to  keep  down  the  percentage 
of  pregnancies,  as,  for  example,  the  fact  that  many  of  these  patients  are 
single,  or,  if  married,  the  husband  has  gonorrhea  (Martin). 


PREGXAXCY    FOLLOWING    COXSERVATISiL 


189 


In  order  to  secure  pregnancy  it  is  not  necessary  to  preserve  the  ovaries  and 
the  uterine  tubes  in  pairs,  as  the  following  instance  will  show : 

M.  B.,  3346,  came  to  me  in  Feb.,  1895,  invalided  by  a  constant  dull  pain 
in  the  lower  abdomen,  with  severe  exacerbations.  On  opening  the  abdomen 
(March  27,  1895),  I  removed  a  left  ovary  converted  into  a  large  hematoma,  and 


riiK  »_'uMiriii)-v  AFTKi:  Removal  uf  thi;  Kight  Tube  and  Left  Ovakv. 
Sliowiucf  the  distauce  separating  the  remaining  tube  and  ovary. 

a  little,  ^vithered  right  tube  with  a  knobbed,  closed  end  covered  with  lymph. 
The  left  tube  was  normal,  and  the  right  ovary  was  also  normal,  except  for 
numerous  shreds  of  lymph  attached  to  it  and  covering  also  the  posterior  surface 
of  the  retroflexed  uterus.  The  uterus  was  held  forward  by  picking  up  a  plica 
of  the  vesical  peritoneum  near  the  symphysis  and  attaching  it  to  the  fundus  on 
both  sides.  The  left  tube  and  the  right  ovary  were  left  hanging  down  into  the 
pelvis,  with  the  fimbriated  end  of  the  tube  4  centimeters  distant  from  the  ovary 
(see  Figs.  308  and  369).  Pregnancy  occurred  in  September  of  the  same  year, 
and  the  patient  had  her  first  child  in  June,  1896.  In  Xov.,  1897,  I  had  to  re- 
move the  left  tube  for  a  ruptured  extra-uterine  pregnancy. 

Uterus  Retroflexed;  Appendages  firmly  Adherent; 
Ovarian  Cysts  Opened;  Pregnancy  within  Four  Months. 
— Dr.  A.  P.  Dudley  {A77ie/\  Gyn.  and  Obs.  Joiu\,  Feb.,  1897)  relates  a  case  of  a 
woman,  twenty -five  years  old,  operated  upon  by  him  in  Dec,  1889.  The  uterus 
was  retroverted,  and  with  the  appendages  firmly  fixed  in  the  pelvic  fioor ;  the 
adhesions  were  broken  up  and  numerous  cysts  in  the  ovaries  punctured  and 
evacuated,  and  the  lining  capsule  scratched  to  cause  it  to  fill  with  a  blood  clot ; 


190  CONSEEVATIVE    OPERATIONS    ON   THE   TUBES   AND    OVARIES. 

the  tubes  were  probed  and  found  patent.  The  uterus  was  held  forward  by  an 
intraperitoneal  shortening  of  the  round  ligaments.  The  patient  left  the  hospital 
in  three  weeks  feeling  well,  and  in  four  months  reported  herself  pregnant ; 
later  she  induced  abortion  by  injecting  hot  water  into  the  uterus. 

Extensive  Inflammatory  Disease  involving  Right  and 
Left  Ovary;  Left  Tube  formal,  Ovary  Atrophied;  Preg- 
nancy.— In  another  patient  of  Dr.  Dudley's,  forty  years  old,  the  uterus  and 
appendages  were  firmly  fixed  in  the  pelvis  by  an  inflammatory  mass. 

The  right  appendages,  hopelessly  diseased  and  involved  in  adhesions,  were 
removed,  but  the  left  tube  was  sound  with  an  atrophic  ovary  ;  sixteen  months 
later,  in  her  forty-second  year,  she  gave  birth  to  a  healthy  boy  weighing  seven 
pounds. 

Left  Pyosalpinx  and  Imbedded  Ovary  removed;  Right 
Adherent  Tube  freed  and  Cystic  Ovary  punctured;  Ad- 
herent Uterus  elevated  and  suspended;  Pregnancy. — This 
patient  of  Dr.  B.  MacMonagle  is  an  interesting  example  of  successful  conserva- 
tism and  an  extraordinary  success  after  suspension  of  the  uterus  ;  she  was  thirty- 
four  years  old  and  had  had  one  child ;  the  abdomen  was  opened  for  extensive 
pelvic  peritonitis  and  retroflexion  with  adhesions.  A  left  pyosalpinx  with  a 
densely  adherent  ovary  was  removed,  and  on  the  right  side  the  tube  was  freed 
from  adhesions  binding  it  down  to  the  pelvic  floor,  and  several  large  cystic  folli- 
cles were  punctured  ;  the  uterus,  adherent  by  its  posterior  surface,  was  elevated 
and  suspended  by  two  sutures.  Within  a  year  she  became  pregnant  and  was 
confined  at  term,  attended  by  a  neighbor  who  acted  as  midwife ;  three  children 
were  born,  all  lived,  and  they  are  now  two  years  old.  ISTormal  involution  went 
on,  and  the  uterus  remains  in  anteposition, 

Retroflexed  Uterus  and  Appendages  Imbedded  in  Adhe- 
sions; Left  Ovary  and  Tube  removed  Piecemeal;  Right 
Ovary  and  Tube  badly  torn,  Tube  broken  off  5  Centimeters 
from  Uterus;  Pregnancy  in  Six  Months. — Dr.  B.  F.  Baer  (^w- 
nals  of  Gyn.  and  Ped.,  Jan.,  1894,  p.  232)  reports  a  case  of  pregnancy  under 
the  most  unusual  circumstances.  The  patient,  thirty-two  years  of  age,  who  had 
a  large  retroflexed  adherent  uterus  with  hard  masses  on  both  sides,  submitted  to 
an  operation,  with  the  express  proviso  that  one  ovary  or  a  part  of  one  should  at 
least  be  left,  that  she  might  not  be  deprived  of  the  possibility  of  offspring.  The 
abdomen  was  opened  in  Feb.,  1891,  and  the  retroflexed  uterus  and  appendages 
were  found  so  covered  by  organized  false  membranes  as  to  be  completely  out  of 
sight.  After  breaking  through  the  false  membranes  with  great  effort,  the  uterus 
was  dissected  loose  and  brought  forward,  covered  with  shreds  of  broken  adhe- 
sions ;  the  left  ovary  and  tube  were  so  firmly  bound  down  to  the  posterior  sur- 
face of  the  broad  ligament  that  they  were  taken  away  jiiecemeal,  and  a  calcare- 
ous mass  was  also  removed  from  the  bed  of  adhesions.  The  right  side  was 
similarly  diseased  and  dissected  loose  in  shreds,  the  tube  being  torn  off  5  centi- 
meters from  the  uterus.  As  Dr.  Baer  was  al)out  to  remove  the  appendages  of 
this  side  too,  he  received  a  positive  injunction  from  the  brother  of  the  patient, 


PREGXAXCY    FOLLOWING    COXSERVATISM:.  191 

w]io  was  a  pliysician  and  was  present,  not  to  proceed,  as  he  preferred  to  assume 
any  risk  rather  tlian  deprive  his  sister  absokitelv  of  all  hope  of  offspring.  The 
abdomen  was  therefore  closed,  an  excellent  recovery  followed,  and  in  fifteen 
months  a  child  was  born. 

Extensive  Pelvic  Inflammatory  Disease;  Kight  Tube 
and  Ovarv  removed:  Pus  Sac  in  Left  Tube  openino-  into 
Bowel;  Left  Tube  amputated;  Pregnancy . — One  of  the  worst 
cases  for  the  complications  it  presents  is  that  of  Dr.  B.  MacMonagle  (see  Polk, 
Trans.  Congr.  Amer.  Phys.  and  Surg.,  189J:,  p.  193). 

The  patient,  twenty-four  years  old,  had  been  married  three  years  without 
pregnancy.  She  had  a  jjehdc  abscess  discharging  at  intervals  through  the  rec- 
tum, and  following  a  dilatation  of  the  cervix  at  the  hands  of  another  specialist. 
When  seen  by  Dr.  MacMonagle  in  Oct.,  1888,  she  was  emaciated,  sallow,  had  con- 
stipation, frequent  urination,  and  night  sweats  ;  the  abdomen  was  scarred  and 
discolored  by  blisters  and  poultices  ;  the  temperature  varied  from  99°  to  101°  ;  a 
bad-smelling  yellowish  discharge  issued  from  the  uterus  and  vagina,  and  pus  and 
blood  apj^eared  in  the  stool  every  few  days  ;  the  uterus  was  fixed,  and  there  was 
thickening  and  tenderness  over  both  ovaries  and  uterine  tubes. 

The  abdomen  was  o^Dened  and  the  o  m  e  n  t  u  m  found  adherent  to  the  uterus 
and  the  neighboring  parts  ;  there  was  a  small  cyst  over  the  right  tube  and  ovary, 
and  extensive  adhesions  of  the  tube  and  ovary  to  the  bowel  and  broad  ligament, 
with  the  fimbriated  end  of  the  tube  bound  down  to  the  ovary.  The  cyst,  ovary, 
and  tube  wei*e  removed  close  to  the  uterus. 

On  the  left  side,  in  attempting  to  enucleate  the  tube  and  ovary,  a  pus  sac  in 
the  pelvis  opening  into  the  bowel  was  broken  into  and  there  was  a  sharp  hemor- 
rhage ;  the  attempt  was  made  to  check  this  by  putting  a  ligature  (Staffordshire 
knot)  deep  doAvn  in  the  broad  ligament,  passing  the  loops  on  one  side  close  to 
the  horn  of  the  uterus  and  on  the  other  outside  the  ovary  ;  when  this  was  drawn 
tight  it  was  found  to  incliide  the  ovary  and  adherent  fimbriated  extremity  of 
the  tube  to  such  an  extent  that  it  was  impossible  to  remove  these  structures  and 
still  leave  enough  tissue  distally  to  prevent  the  ligature  from  slipping ;  only  the 
free  portion  of  the  tube  was  then  cut  out,  and  the  incision  closed  with  a  glass 
tube  drain  inserted.  Two  years  after  she  became  pregnant  and  gave  birth  to  a 
child. 

Ovarian  Cysts  of  Both  Ovaries;  Kight  Ovary  and  Tube 
extirpated;  Left  Cyst  removed,  leaving  a  Piece  of  the 
Ovary  and  the  Tube;  Pregnancy . — A  woman  thirty  years  old  was 
operated  upon  in  May,  1890,  by  Dr.  A.  Sipple  {Central,  f.  Gyn.,  1893,  No.  3, 
p.  43)  for  double  ovarian  tumors  ;  on  the  right  side  no  sound  tissue  was  found, 
and  the  ovary,  about  the  size  of  a  child's  head,  was  removed  with  the  tube  ;  on 
the  left  side  the  ovary  was  about  as  large  as  a  goose's  e^a^,  and  at  its  base  a  strip 
of  macroscopically  normal  ovarian  tissue  was  found ;  the  tumor  was  therefore 
cut  away,  leaving  a  piece  of  ovarian  tissue  at  the  hilum  4  centimeters  long  and 
3  or  4  millimeters  in  thickness,  which  was  sutured  and  dropped.  This  patient 
became  pregnant  in  Aug.,  1891,  and  was  normally  delivered  in  due  time. 


192  CONSERVATIVE    OPERATIONS    ON"   THE   TUBES    AND    OVARIES. 

Left  Ovarian  Cjst  and  Adherent  Uterus;  Half  of  the 
Right  Ovary  removed;  Tube  not  removed;  Pregnancy . — 
In  another  patient  of  Dr.  Dudley's,  twenty-nine  years  old,  an  ovarian  cyst, 
firmly  attached  to  the  posterior  uterine  surface,  was  removed,  leaving  the  uterus 
denuded  ;  one  half  of  the  left  ovary  was  taken  away,  but  the  tube,  though  much 
enlarged,  was  allowed  to  remain,  and  the  uterus  fastened  forward. 

Drainage  was  used  through  the  vaginal  cul-de-sac.  Pregnancy  occurred, 
and  she  miscarried  at  four  months. 

Hematoma  of  Both  Ovaries;  Removal  of  Left  Ovary  and 
Tube;  Resection  of  the  Right  Ovary;  Pregnancy.  Operation 
by  "VV.  M.  Polk,  Dec,  1892. — The  left  ovary,  converted  into  a  hematoma  5  cen- 
timeters in  diameter,  was  removed  with  its  tube  ;  two  thirds  of  the  right  ovary, 
containing  a  hematoma,  was  resected  and  the  remainder  brought  together  by 
suture  ;  the  right  tube  was  not  diseased.  The  patient  recovered  her  health,  and 
when  seen  on  June  5,  1893,  was  four  and  a  half  months'  pregnant. 

A.  Martin  reported  a  case  of  pregnancy  {German  Gyn.  Soc.^  4th  meeting,  at 
Bonn,  May,  1891)  in  a  woman  forty-two  years  old,  operated  upon  in  Oct.,  1888, 
from  whom  the  right  adnexa  had  been  removed  and  the  left  tube  resected  for 
hydrosalpinx.     She  miscarried  in  the  third  month. 

Dr.  Polk  presents  further  a  remarkable  example  of  the  possibility  of  re- 
juvenation in  a  case  of  double  hematosalpinx. 

The  patient,  twenty-two  years  old,  was  operated  upon  in  Oct.,  1890.  The 
right  ovary,  the  seat  of  an  extensive  hematoma,  was  removed  with  the  right 
tube ;  on  the  left  side  the  ovary  was  normal,  but  the  tube,  the  seat  of  a  hemato- 
salpinx, was  cut  off  just  inside  the  dilated  portion,  about  an  inch  from  the  uterus, 
and  the  stump  attached  close  to  the  ovary.  There  were  extensive  adhesions 
on  both  sides.  Two  years  after  the  operation  the  patient  was  delivered  of  a 
healthv  male  child. 


CHAPTEK   XXYI. 

SIMPLE   SALPINGO-OOPHORECTOMY   AND   SALPINGO-OOPHORECTOMY 
FOR  ADHERENT   TUBES   AND   OVARIES. 

A.  Simple  salpingo-oophorectomy. 

1.  Indications  and  contra-indieations  foi-  operation:  1.    For  myoma  of  the  uterus.     2.  For 

osteomalacia.    3.  For  incomplete  development  of  the  genitals.    4.  For  extreme  dysmen- 
orrhea. 

2.  Four  typical  cases  of  castration  for  extreme  dysmenorrhea  (out  of  five  hundred  abdominal 

sections). 

3.  Operation  :  1.  The  incision  and  delivery  of  the  tube  and  ovary.    2.  Ligation  of  the  pedicle 

and  removal  of  the  ovary  and  tube.    3.  Inspection  of  the  field  and  closure  of  the  incision. 

B.  Salpingo-ociphorectomy  for  hydrosalpinx  and  adherent  ovaries  and  tubes. 

1.  Hydrosalpinx:  (1)  Hydrosalpinx  simplex.     (2)  Hydrops  tubae  profluens.     (3)  Hydrosalpinx 

follicularis.     (4)  Tubo-ovarian  cysts. 

2.  Cause. 

3.  Symptoms. 

4.  Treatment:  (1)  Conservative,     a.  Breaking  up  adhesions,     b.  Making  a  new  ostium  in  a 

closed  tube.     c.  Resecting  a  diseased  tube.     (2)  Radical. 

SIMPLE   SALPINGO-OOPHORECTOMY. 

The  simplest  form  of  abdominal  operation,  next  to  the  purely  exploratory 
incision  and  to  the  suspension  operation  for  retroflexion  of  the  uterus,  is  the 
removal  of  tubes  and  ovaries  not  adherent,  and  not  in  any  way  or  but  slightly 
altered  by  disease — that  is,  salpingo-oojjhorectomy. 

The  removal  of  the  normal  ovaries  and  tubes  forms,  as  it  were,  the  type  of 
all  extirpative  operations  upon  the  uterine  tubes  and  the  ovaries,  even  the  most 
complicated,  for  after  the  various  complications  are  met  and  put  aside  the  final 
steps  in  the  enucleation  remain  the  same. 

The  object  of  a  simple  salpingo-oophorectomy  is  an  ar- 
tificial and  premature  induction  of  the  menopause  for  one 
of  several  indications — either  to  secure  the  effect  upon  the  uterine  circulation, 
as  in  checking  the  growth  of  m  y  o  ni  a  t  a ,  to  check  the  prog- 
ress of  an  osteomalacia,  or  to  relieve  the  menstrual  molimina 
in  cases  of  incomplete  development  of  the  genitals  with  functionally  perfect 
ovaries,  and,  in  the  rarest  instances,  for   excessive   dysmenorrhea. 

The  operation  has  also  been  performed  as  the  concluding  step  of  a  Cesarean 
section  to  prevent  future  conception,  but  the  same  end  may  be  obtained  here  by 
simply  ligating  the  uterine  tubes. 

The  various  neuroses,  slich  as  menstrual  epilepsy,  hysteria  and  hystero-epi- 
lepsy,  and  insanity,  do  not  of  themselves  justify  the  removal  of  the  uterine 
tubes  and  the  ovaries.  It  has  long  been  fondly  held  by  gynecologists  that  in 
major  epilepsy  of  a  distinctly  menstrual  type — that  is  to  say,  occurring  always 

193 


194      SIMPLE   SALPINGO-OOPHOKECTOMY    FOE    ADHERENT   TUBES   AXD    OVAEIES. 

during,  just  before,  or  immediately  after  tlie  menstrual  period — the  exjDectation 
of  a  radical  cure  from  the  suppression  of  the  periodical  function  was  fully 
justified,  but  the  facts  of  the  case  do  not  so  far  bear  out  this  assumption. 

I  have  myself  operated  for  epilepsy  in  but  one  case,  that  of  a  feeble- 
minded girl  whose  attacks  were  greatly  aggravated  at  the  monthly  periods ;  she 
improved,  but  was  by  no  means  cured  l)y  the  operation. 

Dr.  S.  Weir  Mitchell,  our  greatest  authority,  says  (  Univ.  Med.  Mag.,  March, 
1897,  p.  389) :  "  In  no  case  seen  by  me  had  ablation  of  ovaries  and  termination 
of  menstruation  cured  an  epilepsy.  I  have  never  sanctioned  such  operations 
where  the  appendages  were  sound.  I  have  agreed  thrice  to  these  operations 
in  epilepsy  with  such  pelvic  disease  as  of  itself  would  justify  oophorectomy. 
In  all  three,  after  some  delay,  the  fits  returned  and  were  in  no  way  permanently 
aided.  ...  I  recall  as  an  illustration  a  case  in  which  there  were  epilej)tic  attacks 
of  great  severity  only  at  the  menstrual  epoch.  The  ovaries  were  apparently 
sound,  but,  as  two  physicians  and  a  surgeon  were  against  me,  my  opinion  was  not. 
regarded  and  ovariotomy  was  performed.  The  attacks,  which  had  been  daily, 
stopped  for  seven  weeks  after  the  operation,  and  the  case  was  hastily  spoken  of 
as  a  great  triumph.  The  patient,  however,  then  became  worse,  and  perma- 
nent loss  of  mind  resulted.  .  .  .  The  ease  of  operation,  the  freedom  from  mor- 
tality, makes  that  seem  of  little  moment  which  should  in  every  case  receive  the 
gravest  consideration.  ...  In  all  my  life  I  have  met  with  but  four  reflex  epi- 
lepsies ;  none  were  from  uterine  or  ovarian  or  tubal  disease." 

I  can  not  do  better  than  cite  the  opinion  of  the  same  eminent  neurologist 
regarding  the  value  of  oophorectomy  in  insanity. 

"  Because  an  insane  woman  is  usually  worse  at  her  period,  it  is  no  reason 
why  the  flow  should  be  stopped  by  operation.  That  the  climacteric  puts  an  end 
to  these  disorders  is  an  old  delusion ;  in  fact,  the  change  of  life,  so-called,  is 
quite  as  likely  to  make  them  worse  as  to  better  them." 

Out  of  but  four  cases  of  neuroses  recalled  by  Dr.  Mitchell,  one  became  worse 
and  three  were  improved  by  operation.  One  woman  of  forty  years,  after  long 
years  of  aggravated  hysteria,  suffered  so  much  from  melancholia  at  her  men- 
strual period  that  she  besought  relief,  and  finally  reluctant  consent  to  operation 
was  given.  This  resulted  in  a  remarkably  improved  physical  condition,  but  the 
insanity  became  abruptly  worse,  and  has  now  lasted  twelve  years. 

In  a  case  of  aggravated  hysteria  of  the  type  so  common  in  France 
but  rare  in  this  country,  the  patient  finally  became  violently  homicidal  at  the 
menstrual  epoch,  Normal  pelvic  structures  were  removed  and  a  gradual  im- 
provement followed,  until  perfect  health  was  regained. 

A  third  case  of  n  y  m  p  h  o  m  a  n  i  a  with  furious  sexual  dreams  at  the  men- 
strual period  was  similarly  treated  and  relieved,  but  it  must  be  borne  in  mind 
that  there  were  also  enlarged  ovaries  and  serious  tubal  disease. 

The  fourth  case  of  menstrual  melancholia  and  maddening  head- 
aches was  also  slowly  relieved  of  the  melancholia,  but  the  periodical  headaches 
persisted ;  in  this  case,  too,  there  was  grave  disease  of  the  tubes  and  ovaries,  so 
that  we  rightly  exclude  this  and  the  preceding  from  our  category. 


SIMPLE    SALPINGO-OOPHOKECTOMY.  195 

It  is  a  question  for  investigation  whether  the  operation  is  justifiable  under 
any  circumstances  in  feeble-minded  girls  with  uncontrollable  sexual  pro- 
clivities, or  for  incurable  masturbation. 

Salpingo-oophorectomj  has  been  frequently  performed  in  the  past  for  the 
sake  of  its  effect  in  jjermanently  diminishing  the  blood  supply  to  the  uterus 
where  the  latter  contains  myomata  which  could  not  be  removed  without  undue 
risk,  but  this  treatment  is  now  no  longer  resorted  to  by  the  best  operators  on 
account  of  its  uncertainty,  as  well  as  on  account  of  the  improved  technique  of 
myomectomy  and  hysteromyomectomy. 

Extreme  d  y  s  ni  e  n  o  r  r  h  e  a  is  an  indication  which  I  accept  with  great 
hesitation,  even  when  the  suffering  is  sufficient  to  impair  the  patient's  health 
seriously,  and  all  other  simpler  plans  of  treatment  have  been  faithfully  tried  and 
have  failed. 

Of  all  operations  connected  with  gynecology,  salpingo-oophorectomy  per- 
formed upon  this  indication  and  for  hysteria  has  been  most  abused,  either 
through  a  want  of  good  judgment  on  the  part  of  the  surgeon  in  recommending 
unsuitable  cases  for  operation,  or  through  his  being  misled  by  a  hysterical 
woman  into  imagining  her  pehnc  condition  worse  than  it  actually  was  the  fact. 

In  all  these  cases  the  advice  of  the  neurologist  and  the  general  j)racti- 
tioner,  as  well  as  that  of  a  conscientious  skilled  gpiecologist,  must  be  sought 
before  deciding  upon  a  radical  operation  the  benefits  of  which  are  at  best 
doubtful. 

Dysmenorrhea  is  but  a  symptom  which  may  arise  from  so  many  other  causes 
than  disease  of  the  ovaries,  that  while  the  removal  of  these  organs  may  pos- 
sibly relieve  the  periodical  monthly  pain,  it  may  at  the  same  time  leave  in  its 
place  a  great  number  of  nervous  symptoms  infinitely  more  distressing  than  the 
menstrual  discomforts.  In  younger  w^omen  the  removal  of  the  ovaries  is  fol- 
lowed by  more  pronounced  nervous  disturbance  than  in  those  who  are  older. 

The  patient  herself  can  never  be  the  right  judge  as  to  the  necessity  of 
removing  the  ovaries.  I  have  seen  young  women  who  suffered  so  severely  at 
the  menstrual  periods  that  they  were  importunate  in  their  demands  for  radical 
relief,  and  were  willing  to  submit  to  any  operation  ;  removal  of  the  ovaries  sup- 
pressed the  function,  but  in  place  of  the  pain,  a  train  of  nervous  symptoms  ap- 
peared, along  with  the  realization  that  they  were  unsexed  apd  could  not  morally 
assume  the  relationship  of  marriage  with  the  hope  of  maternity,  and  profound 
mental  depression  supervened. 

My  attitude  with  regard  to  the  removal  of  the  ovaries  for  dysmenorrhea  will 
be  seen  by  the  fact  that  in  a  recent  series  of  five  hundred  abdominal  sections  at 
the  Johns  Hopkins  Hospital  only  four  cases  were  oj^erated  upon  for  this  reason, 
and  in  three  of  these  the  relief  was  not  what  was  looked  for. 

One  case,  a  woman  of  thirty-eight  years  (M.  H,,  4180),  who  had  borne  four 
children,  suffered  intense  agony  during  the  menstrual  period.  She  was  not 
neurotic,  and  after  seeing  her  through  a  period  there  could  be  no  (piestion  as 
to  the  reality  of  her  sufferings.  For  four  oi-  five  days  before  the  fi<>w  appeared 
she  had  dull  headache  and  bearing-down  pain  in  the  lower  ahdomcn,  and  when 


196      SIMPLE   SALPINGO-OOPHORECTOMY    FOR    ADHERENT   TUBES    AND    OVARIES. 

the  flow  was  once  established,  instead  of  reheving  her  symptoms,  it  only  aggra- 
vated them.  The  pain  then  became  sharjj  and  paroxysmal,  and  the  headache 
tvas  so  intense  that  she  could  stand  no  liglit  in  her  room.  These  symptoms 
always  persisted  for  a  week,  during  which  time  she  was  bedridden. 

The  uterus  was  dilated  and  curetted.  At  lirst  the  retroflexed  uterus  was  sus- 
pended. Both  ovaries  and  tubes  were  found  normal.  For  one  or  two  periods 
subsequent  to  this  operation  she  was  somewhat  better,  but  soon  the  old  pains  re- 
turned with  renewed  severity,  and  for  the  next  year  she  was  a  constant  sufferer. 

She  then  returned  to  the  hospital  and  I  explained  the  effects  of  the  radical 
operation  and  my  reluctance  to  perform  it.  Both  husband  and  wife,  however, 
insisted  upon  it,  and  I  extirpated  ovaries,  tubes,  and  utenis  (March  2,  1896). 
The  patient  was  well  for  a  year  after  the  operation,  and  then  began  again  to 
complain  of  a  variety  of  nervous  symptoms,  so  that  the  success  of  the  operation 
was  only  partial. 

A  second  case  was  that  of  a  nurse  (E.  D.,  3391,  March  23,  1895),  thirty-six 
years  old,  totally  incapacitated  for  one  week  in  every  month  by  severe  menstrual 
cramps.  Total  extirpation  of  ovaries  and  tubes  was  followed  by  complete  relief, 
and  she  has  since  been  able  to  work  without  interruption. 

In  the  two  other  cases  the  patients  had  enlarged  ovaries  in  which  the  numer- 
ous dilated  Graafian  cysts  were  distributed  underneath  the  thick  tunica  a  1  - 
buginea  of  the  ovary. 

One  woman  was  twenty-two  years  old,  and  her  relief  from  her  pelvic  symp- 
toms has  been  complete,  while  her  subsequent  history  (J.  S.,  3333,  Feb.  25,  1895) 
serves  well  to  show  that  the  dysmenorrhea  is  often  only  the  local  expression  of  a 
constitutional  tendency,  and  that  when  the  pelvic  pain  is  relieved  nervous  out- 
breaks in  various  other  parts  of  the  body  are  prone  to  occur.  Soon  after  the 
operation  she  suffered  from  a  severe  facial  neuralgia  for  which  she  had  all  her 
teeth  extracted.  She  next  had  an  attack  of  sneezing  which  lasted  almost  con- 
tinually for  three  days,  weakening  her  so  that  she  nearly  died.  She  is  now  so 
weak  that  she  can  work  but  little,  and  suffers  from  constant  shortness  of  breath. 
Defecation  is  extremely  painful,  and  there  is  an  obstinate  constipation,  necessi- 
tating the  constant  use  of  medicines. 

The  second  patient,  also  a  young  woman  of  twenty-two,  had  suffered  since 
menstruation  began  with  almost  a  continuous  bloody  discharge.  The  menstrual 
periods  were  irregular  and  very  painful,  and  she  had  long  been  a  confirmed 
invalid.  All  forms  of  treatment,  including  the  tonics,  exercise,  and  diet,  had 
been  instituted  without  relief  ;  instead  of  improving,  she  gradually  lost  ground. 
I  studied  the  case  carefully,  and  somewhat  reluctantly  consented  to  operate. 

The  patient  ceased  to  menstruate  after  the  operation,  and  has  had  no  flow 
for  eighteen  months  ;  she  has  gained  flesh  and  strength,  and  her  color  is  better, 
but  the  nervous  symptoms  are  distressing,  the  flushes  and  sweatings  and  a 
variety  of  bizarre  sensations  keeping  her  constantly  miserable.  Her  depression 
at  times  verges  onto  melancholia. 

Since  the  term  "  cystic  ovary  "  has  been  used  so  frequently,  as  though  it 
were  a  pathological  condition,  to  justify  many  operations  for  dysmenorrhea,  it 


OPERATION.  197 

should  be  distinctly  understood  that  the  presence  of  several  large  Graafian  fol- 
licles is  not  pathological,  except  in  rare  instances  in  which  the  ovary  is  often 
twice  as  large  as  normal,  the  tunica  albuginea  is  thick  and  dense,  and 
multiple  cysts  may  be  seen  shining  through  it.  On  section,  the  capsule  is  seen 
as  a  thick,  white,  non- vascular  area,  and  there  is  only  occasional  evidence  of  rup- 
tured follicles. 

In  the  light  of  our  present  knowledge  of  the  pathology 
of  the  ovary,  the  attempt  to  justify  the  removal  of  small 
"cystic  ovaries"  must  be  denounced  as  both  unscientific 
and  immoral. 

Operation. — The  operation  is  an  epitome  of  all  the  operations  for  the  re- 
removal  of  diseased  appendages,  for  the  effort  of  the  operator  in  the  most  dif- 
ficult cases  is  usually  to  reduce  them  to  the  type  of  the  simple  enucleation  of 
the  tubes  and  ovaries  by  first  eliminating  the  complications  and  then  completing 
the  operation  as  a  simple  salpingo-oophorectomy. 

The  Incision  and  Delivery  of  the  Ovary  and  Tube . — The 
patient  should  be  placed  upon  the  table  with  the  pelvis  elevated,  and  an  incision 
from  4  to  6  centimeters  (1^  to  2^  inches)  long — longer  if  the  abdominal  walls 
are  unusually  thick — should  be  made  through  the  linea  alba,  beginning  2 
or  3  centimeters  above  the  symphysis  pubis. 

As  soon  as  the  abdomen  is  opened,  the  index  and  middle  fingers  are  intro- 
duced and  conducted  along  the  under  surface  of  the  abdominal  wall  to  the  sym- 
physis pubis,  and  from  the  symphysis  down  over  the  bladder  onto  the  uterus, 
and  out  over  the  cornu  uteri  to  the  broad  ligament,  behind  which  the  tiibe 
and  ovary  are  ordinarily  found  and  picked  up. 

Futile  efforts  to  pick  up  the  ovary  and  tube  and  draw  them  through  the 
small  incision  often  embarrass  the  beginner.  The  best  way  is  to  carry  the  fin- 
gers to  the  outer  extremity  of  the  broad  ligament,  and  then,  turning  the  palmar 
surfaces  astride  the  broad  ligament  toward  the  uterus,  to  carry  them  down  into 
the  pelvis,  and  bring  them  up  toward  the  cornu  uteri,  so  as  to  hook  up 
both  ovary  and  tube  together,  which  may  now  be  drawn  easily  out  through  the 
incision  and  tied  off. 

The  Ligation  of  the  Pedicle  and  Removal  of  the  Tube 
and  Ovary  . — The  structures  to  be  removed  are  the  entire  length  of  the  tube, 
the  ovary  with  its  hilum  and  a  portion  of  the  utero-ovarian  ligament,  together 
with  their  blood  vessels,  lymphatics,  and  nerves.  The  chief  risk  of  the  opera- 
tion lies  in  the  liability  to  hemorrhage  from  improper  control  of  the  blood 
vessels. 

The  uterine  and  ovarian  vessels  nmst  now  be  tied  separately,  while  the  non- 
vascular portion  of  the  broad  ligament  between  them  is  left  free.  This  avoids 
the  tension  of  the  broad  ligament  produced  by  binding  its  pelvic  and  uterine 
extremities  together  by  interlocking  ligatures,  and  so  obviates  the  imminent  risk 
of  hemorrhage  as  soon  as  any  tension  is  put  upon  the  ligament  by  retching, 
straining,  etc.  (see  Some  Sources  of  Hemorrhage  in  Abdominal  Pelvic  Opera- 
tioiiii.     Johns  Iloph.  IIosp.  Bq>.,  iii,  1894,  p.  419). 


198      SIMPLE    SALPIXGO-OOPHORECTOMY    FOR    ADHERENT   TUBES    AND    OVARIES. 

It  is  best  to  use  fine  silk  ligatures  in  all  cases  when  large  vessels  are  to  be 
controlled. 

The  first  ligature  includes  the  ovarian  veins  and  artery,  and  is  passed  through 
the  clear  space  in  the  broad  ligament  and  tied  near  the  pelvic  brim  over 
the  top  of  the  infundibulo-pelvic  ligament  well  beyond  the  fimbriated  extremity 
of  the  tube.  A  second  ligature  of  catgut  is  applied  to  the  utero-ovarian  liga- 
ment posteriorly.  A  third  ligature  is  passed  over  the  top  of  the  l)road  ligament 
at  the  c  o  r  n  u  uteri,  embracing  the  uterine  vessels  which  are  visible  and  the 
isthmus  of  the  tube. 

In  order  to  fix  the  ligatures  so  that  there  will  be  no  danger  from  slipping 
over  the  top  of  the  pedicle  when  the  ovary  and  tube  are  removed,  the  free  liga- 
ture may  be  carried  over  the  top  of  the  ligament,  or  over  the  cornu,  and 
made  to  transfix  a  small  portion  of  the  tissue  in  a  reverse  direction  from  that  in 
which  it  passed  through  the  broad  ligament  the  first  time. 

The  clear  space  is  a  triangular  surface  near  the  upper  outer  extremity  of 
the  broad  ligament  free  from  vessels,  bounded  by  the  ovarian  vessels  above, 
the  pelvic  wall  on  the  outer  side,  and  the  round  ligament  below  and  on  the 
inside.  It  is  developed,  or  made  larger,  by  pulling  up  the  top  of  the  broad 
ligament.  If  the  finger  is  pushed  into  this  space  from  behind  forward,  the 
anterior  and  posterior  layers  of  the  broad  ligament  are  brought  together,  and 
the  furrows  in  the  skin  of  the  finger  are  often  clearly  visible  through  them. 
I  utilize  the  clear  space  in  the  following  manner  in  passing  the  ligatures  :  The 
structures  to  be  removed  are  drawn  well  up,  and  the  finger  is  passed  down 
behind  the  broad  ligament  under  the  ovarian  vessels  and  pushed  forward  into 
the  clear  space.  A  careful  observation  is  then  made  to  be  sure  that  all  the 
large  ovarian  veins  lie  above  and  none  of  them  lie  below  the  end  of  the  finger, 
A  silk  suture  of  intermediate  size  is  then  drawn  through  the  clear  space  from 
before  backward  by  means  of  a  needle  and  carrier,  and  tied  tightly  over  the  top 
of  the  vessels. 

After  the  ligation  the  ovary  and  tube  are  removed  by  cutting  the  pedicle  at 
least  1  centimeter  from  the  ligatures. 

Particular  attention  must  be  given  to  the  removal  of  the  entire  ovary,  cut- 
ting through  a  point  in  the  ovarian  ligament  well  away  from  the  ovary,  and 
then  cutting  under  the  hilum  well  away  from  the  ovarian  tissue. 

As  the  outer  extremity  of  the  Ijroad  ligament  is  severed,  its  stump,  with  the 
ovarian  vessels,  retracts  up  to  or  over  the  brim  of  the  pelvis,  and  between  this 
and  the  cornu  uteri  there  is  only  the  thin  falciform  edge  of  the  anterior 
and  posterior  peritoneal  layers  of  the  broad  ligament.  If  any  small  bleeding 
points  are  noted  in  this  area  they  must  be  caught  with  forceps  and  controlled 
with  fine  catgut  ligatures. 

Inspection  of  the  Field  and  Closure  of  the  Incision . — 
Finally,  after  both  appendages  have  been  removed,  a  careful  inspection  should 
be  made  before  closure,  in  order  to  determine  whether  there  is  any  bleeding  and 
whether  the  stumps  are  well  tied,  so  as  to  lessen  the  likelihood  of  hemorrhage 
after  closure  of  the  incision.      If  any  one  of  the  uterine  ligatures  or  of  the 


PLATE  X 


X  16 


Figl 


F'lo  2 


M  Brodelfer 


Llli.LPranl&CaBo:, 


irteiies  appear  insecure  or  doubtful,  a  second  ligature  should  It 
.  .  tiie  pedicle  to  make  it  secure, 
f  is  not  necessary  to  wash  out  the  abdomen  or  the  pelvi«i, 

ver  to  be  used. 

)atient  is  now  let  down  from  the  elevated 

vn  down  over  the  small  intestines  as  the 

•  see  that  no  loop  of  intestines  has  slippe*  i 

neration  is  completed  by  closing  the  ^nr•■ 

.  res,  catgut  to  the  peritoneal  ' 
ctud  muscle,  ■■  ^   ■  "2:ut  to  the  fat  i; 
lar  suture  ol  or  silver  wire — ; 

•Unique  of  abdominal  operati*   ^ 


name  "hydrosa^g^j^jp^jQj^  QP  p-^^rpj,  -JJ.J  , 

watery  accumulation;  thel«;'a  ,.-  ilic'-etore  tK.r  .'  .  te.     It  (i.K-!8 

.Fig.  1,— Hydrq$alpinx; ,  sinjplex  (xl6).,  Cross-section  through  the  middle  of  the 
tube,  showing  the  teatlike  and  branching  folds  projecting  into  the  lumen.  The  smaller 
folds  present  marked  constrictions  at  their  bases.  "        ' 

Fig.  2.^HydrosaIpihx  follicularis  (x8).  Cross-section  from  a  point  at  the  junction 
of  the  middle  and  outer  third  of  the  tube.  Surrounding  the  central  lumen  are  many 
large  and  small  round  or  irregularly  shaped  cavities.  The  dilatation  is  greater  on  the 
free  convex  upper  surface  than  below. 

I  »i'(  jtiuens. 


drosalpinx  Simplex. — In  simple  h; 


-ide  or  behind  the  aterus;  if  both  >                                            hes 

Items  in  ■  "    ■             ""                                          lube  is 

a  the  su]  ■  -  <'«>wn 

!vic  floor.     If  th  uty 

'Oition  ^.  n — that 

"11        It        1-  •                                                                                                                                         llli.I-        o 


.IX  aTAJ^I  10 


;i083a 


erf  J  lo  olbbiia  9ift  rf'guofilJ  nox;t098-88O'i0     .(blx)   xaLqmia  xfricflBao'ibx;H — .1  .oi'5 
•lallBfua  9ilT     .uaraul  axfi  oicii  'gniioaioiq  abUyt  ^firiforrBid  baa  9iIilJB9J  grfi  •gfliworfg  ,9djjJ 

.898Bcf  119 ffi  Ifi  anoiiohjgnoo  bgjIiBin  ia9a9'iq  ahlo^ 
iioiioaul  oiii  iB  inioq  b  mcn\  rroiioea-aaoiQ     .(8  x  )  aiiBluoillol  zniqlBaoib^H — .S  .m'i 
XaBia  9'iB  n9mu[  Iciirieo  odi  ■gnibauoTiwS     .adxji  9rfi  ^o  btidi  igjjjo  briB  eibbiia  atli  ^o 
9xlj  ao  i9.tB9Tg  ax  noiJB^Blil)  9xIT     .ggiiiveo  bgqsrla  :y;I'iBljj^9Tix  lo  bnuoi  IlBrna  bas  9^ibI 

.7/ o [•:♦((  KXirii  aafiliua  i9qqxx  x9Vfloo  eeri 


SALPINGO-OOPHORECTOMY   FOR    HYDROSALPIXX.  199 

ovarian  arteries  appear  insecure  or  doubtful,  a  second  ligature  should  be  thrown 
around  the  pedicle  to  make  it  secure. 

It  is  not  necessary  to  wash  out  the  abdomen  or  the  pelvis,  and  drainage 
ought  never  to  be  used. 

The  patient  is  now  let  down  from  the  elevated  position,  and  the  omentum  is 
then  drawn  down  over  the  small  intestines  as  they  drop  into  the  pelvis  and  in- 
spected to  see  that  no  loop  of  intestines  has  slipped  through  one  of  its  accidental 
oj^enings. 

The  operation  is  completed  by  closing  the  incision  with  the  three  or  four 
layers  of  sutures,  catgut  to  the  peritoneal  layer,  silver  wire  or  silkworm  gut  to 
the  fascia  and  muscle,  and  catgut  to  the  fat  if  the  walls  are  thick,  and  finally  a 
subcuticular  suture  of  catgut  or  silver  wire — all  as  described  in  Chapter  XXI, 
on  the  technique  of  abdominal  operations. 

SALPIXGO-OOPHORECTOMY  FOR  HYDROSALPINX  AND  FOR  ADHERENT  TUBES 

AND   OVARIES. 

The  name  "hydrosalpinx"  is  applied  to  a  uterine  tube  which  contains  a 
watery  accumulation ;  the  term  is  therefore  not  scientifically  accurate.  It  does 
not  in  any  way  define  the  morbid  process  that  brings  about  such  an  accumu- 
lation; it  simply  describes  a  prominent  clinical  feature.  This  accumulation  of 
fluid  is  due  to  an  occlusion  of  the  tube,  forming  a  retention  cyst. 

For  clinical  convenience  the  various  forms  of  hydrosalpinx  may  be  grouped 
as — 

1.  Hydrosalpinx  simplex. 

2.  Hydrops  tubse  profluens. 

3.  Hydrosalpinx  follicularis. 

4.  TuI)0-ovarian  cysts. 

1.  Hydrosalpinx  Simplex. — In  simple  hydrosalpinx  there  is  a  conical  disten- 
tion of  the  tube,  which  is  greatest  at  the  fimbriated  and  least  at  the  uterine  end. 
On  opening  the  abdomen  (see  Fig.  370),  the  tube  looks  like  a  transparent  thin- 
balled  sac  beside  or  behind  the  uterus ;  if  both  sides  are  involved,  the  tubes 
hang  back  over  the  uterus  like  saddle-bags.  The  uterine  end  of  the  tube  is 
usually  on  a  level  with  the  superior  strait,  while  the  dilated  extremity  dips  down 
toward  the  pelvic  floor.  If  the  tube  is  only  moderately  distended,  the  fluid  may 
all  be  lodged  in  that  portion  which  offers  the  least  resistance  to  expansion — that 
is,  in  the  ampulla  ;  when  it  is  excessively  enlarged  so  as  to  hold  half  a  liter,  a 
liter,  or  more  of  fluid,  it  rises  up,  filling  the  lower  abdomen  and  partaking  of 
many  of  the  clinical  characteristics  of  a  parovarian  cyst  (see  Figs.  371,  372). 

Peaslee  cites  an  extraordinary  case,  if  his  interpretation  is  to  be  credited, 
which  contained  18  pounds  of  fluid  [Ovarian  Tumors  and  Ovariofnr/iy^  1872, 
p.  lo:,). 

One  or  more  kinks  are  commonly  found  in  the  tube  before  its  removal,  due 
to  the  flexures  necessary  to  accommodate  its  posture  to  the  more  resisting  sur- 
Tounding  structures.  Adhesions  are  uniformly  found  at  the  fimbriated  end,  and 
54 


200      SIMPLE    SALPINGO-OOPHORECTOMY    FOR    ADHERENT   TUBES   AND    OVARIES. 

these  commonly  hold  the  tube  down  to  the  pelvic  floor ;  adhesions  to  the  ovary 
and  to  the  contiguous  pelvic  wall  are  also  common.  The  dorsum  of  the  tube 
is,  however,  usually  free.  In  rare  instances  the  ampulla  is  simply  closed  and 
there  are  no  pelvic  adhesions. 

When  the  tubal  walls  are  thin  and  unruptured,  s  t  r  i  se  may  often  be  seen 
on  the  inside,  parallel  to  its  long  axis  ;  these  are  folds  in  the  mucosa.  The  inner 
surface  is  glistening  and  pinkish  in  color.     Microscopically,  the  muscular  layers 


Fig.  370. — Double  Hydrosalpinx,  drawn  from  Nature,  showing  the  Relations  between  the  Large 
Tubes  dilated  with  Clear  Fluid  and  the  Uterus  and  the  Posterior  Pelvis. 

Note  the  flexions  of  the  right  tube  and  the  adhesions  from  the  uterine  cornu  to  the  ampulla. 

in  the  wall  of  the  tube,  in  the  cases  with  the  least  distention,  may  appear  nor- 
mal ;  in  other  cases  they  are  thinned  out  until  they  may  be  nearly  all  gone.  Be- 
tween the  muscular  bundles  a  connective-tissue-cell  proliferation  is  often  found, 
and  the  intermuscular  connective  tissue  may  be  loose  and  edematous.  Hyper- 
trophy of  the  muscular  coat  does  not  occur. 

The  mucous  lining  of  the  tube  presents  the  most  remarkable  and  character- 
istic changes.    The  folds,  normally  so  luxuriant  and  complicated  in  their  branch- 


f^         \ 


tfT     .bs^'rnz 


ffcvH 


luscular 


DESCRIPTION  OF  PLATE  XII. 

Hydrosalpinx  simplex  ( x  70).  A  small  portion  of  Plate  XI,  Fig.  1,  magnified.  The 
peritoneal  coat  is  here  free  from  adhesions  and  the  muscularis  is  normal.  The  tube  is 
lined  by  a  single  layer  of  cylindrical  epithelium  and  the  stroma  of  the  folds  is  normal. 


tnd  chfu 
ii  their  br 


PLATE  XII 


]^%M^i^ 


X  70 


■  Brrtdel.fec 


LHh.LPcang&CaBoslm.USA. 


HYDROSALPINX    SIMPLEX. 


201 


ings,  are  separated  from  one  another  as  a  result  of  the  distention ;  they  are  recog- 
nized as  branched  folds  and  fingerlike  projections. 


.  ■  1 


Fig.  371. — Large  Left  IIydko.salpinx  with  Numerous  Adhesions;   Normal  Ovaries,  Kioht  Tube,  and 

Uterus. 
Drawn  to  scale  below.     March  30,  1895. 

The  epithelium  may  retain  its  cilia  even  in  a  tube  which  is  markedly  dis- 
tended ;  it  always  occurs  in  a  single  layer,  cylindrical  and  cuboidal. 


Fio.  372.— Double   IIydro.salpinx,  with   .\i)Iik.'<i(>ns   mjiDoixo  the  Angles  in  the  Tuues  and  binding 
DOWN  the  Utekus  bv  its  Posterior  Sui£Kace.     ALvy  21,  1805.     Natural  Size. 


202      SIMPLE    SALPINGO-OOPHORECTOMY    FOR    ADHERENT   TUBES   AND    OVARIES. 

In  some  cases  calcified  plates  are  found,  and  in  one  of  my  patients  I  found  a 
long  irregular  calculus  fastened  by  one  end  to  the  istlinnis  and  projecting  into 
the  lumen  of  the  dilated  tube. 

In  another  instance  I  found  a  large  hydrosalpinx  associated  with  a  congenital 
deficiency  in  the  tube,  dividing  its  ampulla  into  two  parts,  of  which  the  outer  end 
was  entirely  disconnected  with  the  uterine  end  and  the  isthmus  (see  Fig.  377). 


Fig.  373. — Hyduosalpinx. 

The  laro'e  bulbous  dilated  tube  is  filled  with  serumlike  fluid  and  is  entirely  free  from  any  adhesions  to 
the  ovary.     The  opposite  tube  and  ovary  were  densely  matted  together.     No.  447.     iS'atural  size. 

2.  Hydrops  Tubse  Profluens. — This  form  of  hydrosalpinx  is  characterized  by 
the  remarkable  clinical  sign  of  a  periodical  outflow  from  the  tube  into  the 
uterus,  the  vagina,  and  so  out  over  the  person.     Martin  found  four  cases  out 


Fio.  374. — Hydrosalpin.v  with  Few  Convolutions. 

The  left  tube  is  intimately  adherent  to  the  ovary  be- 
low on  the  right.  Three  glLstenintr  subperitoneal  cy.sts 
are  seen  where  the  tube  joins  the  ovary.  C.  M.,  No.  223. 
Natural  size. 


Hydrosalpin.x    shown    in    Figure 
374,  SEEN  IN  Longitudinal  Section. 

The  ampulla  of  the  tube  is  markedly  dilated 
throughout  and  ends  in  a  large  bulbous'  extrem- 
ity. The  ovary  is  seen  flattened  out  below  the 
eyst.  Note  the  parallel  folds  of  the  tubal  muco- 
sa, ending  abruptly  in  little  bulbous  extremities. 


of  five  hundred  cases  of  tubal  disease.  Landau  states  that  the  muscular  walls  of 
the  tube  are  hypertrophied.  The  manner  of  discharge  of  the  fluid  varies,  occur- 
ring either  constantly  with  periods  of  exacerbation,  or  at  intervals  of  hours  or  of 
several  days.  After  the  formation  of  a  definite  painful  tumor  the  tube  is  evacu- 
ated spontaneously  with  pain,  and  the  tumor  disappears ;  one  of  my  cases,  a  large, 


HYDROSALPINX    FOLLICULARIS. 


203 


stout  woman,  was  made  miserable  by  the  recurring  paroxysms  of  pain.     The 
amount  of  discharge  may  be  as  much  as  half  a  liter  in  twenty-four  hours ;  when 


Fig.  376. — Hydrosalpinx  containing  a  Nodular  S-shaped  Calculus  lying  in  the  Lumen  of  the  Tube, 

WHICH  IS  Adherent  to  the  Ovary. 

The  calculus  is  shown  in  detail  in  the  outline  figure  to  the  right.     Cambridge,  July,  18'J4. 

it  accumulates  in  the  vagina,  as  during  the  night,  on  rising  it  may  escape  like  a 
gush  of  warm  water,  much  as  if  the  bladder  had  suddenly  emptied  itself. 

C  o  d  e  i  n  sometimes  has  a  marked  effect  in  controlling  the  flow,  but  it  does  not 
give  permanent  relief.    Removal  of  one  or  both  tubes  alone  will  cure  the  disease. 


#- 


Fio.  377. — IIydrcsalpin.v,  with  Congenital  Deficiency  in  the  Tiise. 

The  tube  ends  in  ii  group  of  three  cysts,  and  these  are  connected  with  tlie  isolated  subperitoneal  cj'St  on 
tlie  ritrht  by  a  thin  band  of  peritoneum  in  which  there  is  no  portion  of  a  tube.  The  fimbriated  eiul  of  the 
tube  lies  beyond  the  single  cyst. 

3.  Hydrosalpinx  Follicularis.— In  follicular  dropsy  the  tube  is  usually  of  small 
size — not  more  than  3  centimeters  in  diameter- — and  appears  externally  like  the 
simple  dropsical  tube  just  described.  On  cross-section,  however,  the  lumen  of 
the  tube  is  often  diminished  or   altogctlier  displaced  by  an  open  network  of 


204      SIMPLE    SALPINGO-OOPHORECTOMY    FOR    ADHERENT   TUBES   AND    OVARIES. 

tissues  developed  in  its  inner  wall  and  forming  oval  spaces  varying  in  size  from 
a  pin-point  to  8  millimeters  (see  PI.  XI,  Fig.  2,  and  PI.  XIII).  These  cavities 
are  filled  with  fluid,  and  apparently  communicate  with  one  another. 

The  muscular  coat  shows  little  alteration,  with  the  exception  of  some  con- 
nective tissue  cell  proliferation  between  the  bundles. 

The  folds  of  the  mucosa  are  sparse  or  absent,  and  the  mucosa  itself  is  occu- 
pied by  alveoli  which  are  variously  subdivided  by  partitions ;  the  large  alveoli 
are  lined  by  cuboidal  epithelium  and  the  smaller  ones  by  cylindrical  cells.  This 
may  be  the  outcome  of  an  endosalpingitis  follicularis  described  by 
A.  Martin ;  Orth  states  that  the  alveoli  or  gland  like  spaces  may  become  cystic. 

Out  of  eleven  cases  of  hydrosalpinx,  four  were  follicular  and  two  of  them 
were  bilateral.  One  case  presented  a  follicular  hydrosalpinx  on  the  left  and 
a  simple  hydrosalpinx  on  the  right,  tending  to  show  the  close  genetic  relation- 
ship between  the  two  varieties. 

4.  Tubo-ovarian  Cysts. — A  tnbo-ovarian  cyst  is  formed  by  a  communication 
between  a  tube  and  a  cyst  of  the  ovary,  so  that  fluid  may  pass  freely  from  one 
to  the  other.  The  dropsical  tube  in  these  cases  ends  in  a  bulbous  enlargement 
as  big  as  a  thumb  or  a  child's  head.  What  is  most  remarkable  in  these  cases  is 
the  fact  that  the  fimbriated  end  of  the  tube  is  often  found  spread  out  over  the 
inner  surface  of  the  cyst.  J.  Bland  Sutton  {Surg.  Dis.  of  Ov.  arid  Fal.  TuheSy 
London,  1896,  p.  102),  who  has  made  an  admirable  study  of  this  condition, 


Fig.  378. — Right  Tubo-ovakian  Cyst. 

The  tube  above  ends  in  a  bulbous  e.xtremity,  fused  with  the  ovary,  with  only  a  sliifht  .sulcus  between 
thcni.  The  ovarian  lii^ament  is  shown  below,  leading  out  to  the  cystic  ovary.  By  cuttinsc  the  cyst  open  in 
the  direction  of  the  dotted  line,  the  interior  of  the  cyst  is  seen  as  in  Fig.  379.     Path.  No.  605.     Natural  size. 


bringing  his  wide  acquaintance  with  comparative  pathology  to  his  aid,  considers 
that  these  tumors  are  due  to  the  presence  of  a  tunic  of  the  peritoneum,  which 
occasionally  invests  the  human  ovary  in  the  same  way  that  the  funicular  pouch 
clothes  the  testicle,  and  similar  to  the  peritoneal  pouches  in  some  animals,  and 
for  this  reason  he  calls  the  condition  an  "  ovarian  hydrocele." 

One  of  my  cases  of  tubo-ovarian  cyst,  of  small  size,  is  seen  in  Figs. 
378  and  379 ;  I  have  also  had  one  case  in  which  the  tumor  in  the  left  side  was  as 
big  as  a  man's  head  and  filled  with  a  limpid  fluid ;  the  valvelike  opening  out 


;   gWOxig    CtWO. 

w.riquoDO  s'r    •••■ 
b  omoa  niatnoo  Bniou 


/.oiT^iHoaaxi 

IT        .(OT  .: 

'ixIyo  xfiiw  iWxxil  6 


/ 


This 


DESCRIPTION  OF   PLATE  XIII. 

Hydrosalpinx  follicularis  ( x  70).  The  peritoneum  shows  a  few  recent  adhesions  ; 
the  muscularis  has  almost  disappeared  and  its  place  is  occupied  by  connective  tissue. 
The  small  "  alveoli  "  are  lined  with  cylindrical  epithelium,  the  larger  ones  with  cuboidal 
e]>ithelium.  cylindrical  in  protected  areas.  The  lumina  contain  some  desquamated  epi- 
thelium -,  the  stroma  is  almost  normial. 


*!(■!> 


PLATE  XIII. 


^^I^'fe^^^''^'^'"  r^'S 


=fg-_^:- ?^-^^-^^'^^--<;^S^-'''>.^'' '       -   ->•    ^*?^'--^-«i::.-,  ■  -^r^  :-:i.>?'-ii••^A'r.-^ 


■:^^vi.. 


X  70 


ei.fer. 


Lih  LPtanSiCoiBodm,U5A 


Fig.  380. — Tubo-ovarian  Cyst  from  the  Right  Side. 

The  uterine  tube  crosses  the  cyst  in  the  form  of  an  </> ;  at  its  right  extremity  it  is  kinked  and  adherent 
to  a  piece  of  the  uterine  cornu  which  has  been  excised  with  the  tumor.  The  tube  ends  in  the  domelike 
prominence  above  and  to  the  left.  A  small,  clear  subperitoneal  cyst  marks  the  border  line  between  the 
ovarian  cyst  and  the  tube.     March  8, 1894.    Yb  natural  size. 


Fio.   381. — Tubo-ovarian   Cyst   divided   so   as  to   show   the   Large    Ovarian   Cyst   with   the   Ovary 

Flattened  Out  on  its  Surface  Below. 

Above,  the  tube  is  seen  divided  twice  ;  the  smaller  dark  opening  shows  the  reticulated  appearance  of  the 
tube,  while  the  larger  opening  shows  the  dilated  ampulla  with  its  sickle-shaped  opening,  through  which 
the  tube  communicates  freely  with  the  ovarian  cyst  below. 


TUBO-OVAKIAN    CYSTS.  205 

of  tlie  tube  was  partly  surrounded  by  a  fringe  of  fimbriae  spread  out  on  the 
inner  wall.  Bland  Sutton  says  these  cysts  occasionally  suppurate,  but  this  I 
have  never  seen. 

The  inner  surface  in  one  of  my  cases  was  lined  by  flat  epithelium  and  in 
another  by  cuboidal.  The  fluid  is  clear  and  watery  and  does  not  contain  any 
pseudo-niuein. 

Etiology. — The  etiology  of  hydrosalpinx  is  not  yet  clear.  One  thing, 
however,  is  quite  certain,  and  that  is  that  it  may  be  produced  by  any  cause 


Jib  *=s<^^ 

Fig.  379. — Tubo-ovarian  Cyst  laih  iitkn. 

Showinjr  the  orifice  and  flmbriated  extremity  of  the  tube  and  the  distribution  of  the  timlirite  over  the 
interior  of  the  cyst,  forming  a  so-called  •'  ovarian  hydrocele." 

which  closes  the  fimbriated  extremity  of  the  tube  without  destroying  its  lumen. 
In  this  way  an  infection  traveling  out  through  the  uterus  and  the  tube  into 
the  peritoneum  causes  a  hydrosalpinx  by  drawing  together  the  peritoneal  sur- 
faces of  the  tube  until  it  is  closed. 

If  the  infection  is  a  violent  one  and  j)roduces  a  catarrhal  or  a  suppurative 
salpingitis,  the  sealing  up  of  the  tube  is  Nature's  best  way  of  protecting  the 
peritoneal  cavity  from  a  general  infection ;  then  with  the  cessation  of  the  sup- 
purative process  a  hydrosalpinx  may  develop.  Landau  states  that  a  pyosalpinx 
may  terminate  in  a  hydrosalpinx  by  the  pus  cells  undergoing  fatty  degenera- 
tion and  leaving  the  watery  elements  behind. 

Bland  Sutton  (ibid.,  p.  220)  liolds  that  hydrosalpinx  is  often  a  late  stage  of 
pyosalpinx  for  these  reasons :  (1)  Hydrosalpinx  is  not  found  in  acute  cases  ; 
(2)  in  many  chronic  cases  hydrosalpinx  is  found  on  one  side  of  the  uterus  and  a 
progressive  pyosalpinx  on  the  other ;  (3)  the  ampulla  of  a  tube  may  be  dilated 
into  a  hydrosalpinx,  and  the  isthmus  contain  pus  ;  (4)  the  fluid  contained  in  a 
hydrosalpinx  will '  sometimes  be  colorless,  but  the  recesses  of  the  tube  contain 
caseous  material  and  cholesterin ;  (5)  the  dilated  portion  of  the  tube  in  hydro- 
salpinx may,  as  in  pyosalpinx,  communicate  with  an  enlarged  ovarian  follicle  to 
form  a  tubo-ovarian  cyst. 

It  is  a  remarkable  fact  that  both  the  tubal  mucosa  and  the  nniscular  walls 
usually  show  little  or  no  evidences  of  any  previous  inflammatory  process.  I  do 
not,  therefore,  believe  that  the  disease  is  often  a  sequel  of  a  pyosalpinx. 

That  the  process  may  be  a  slow  one  is  evident  from  the  numerous  cases  in 
which  the  fimbriated  end  of  the  tube  is  found  in  all  stages  of  closure;  in  one 
the  ends  are  being  turned  slightly  in  and  the  movements  restricted  by  a  band  or 


206      SIMPLE    SALPINGO-OOPHORECTOMY    FOR   ADHERENT   TUBES   AND    OVARIES. 

a  collar  of  Ijmpli  just  back  of  the  fimbrise ;  in  another  the  end  of  the  tube  is 
rounded  off  and  bulbous,  but  from  the  center  a  rosette  of  fimbriae  still  projects ; 
a  little  later  a  little  red  bud  hangs  out  of  a  minute  orifice ;  finally  this  disa^jpears 
within  and  the  closure  is  complete. 

At  the  point  of  completed  closure  there  is  a  mass  of  scar  tissue,  and  the  tube 
often  presents  a  marked  depression  from  which  bands  of  connective  tissue 
radiate  out  to  the  periphery. 

The  turning  in  of  the  fimbriae  is  to  be  accounted  for  in  the  following  way : 
The  inflamed  peritoneum  is  the  only  surface  to  which  the  lymph  can  become 
attached,  and  every  time  a  contraction  is  made  a  gain  is  eifected  and  more  mu- 
cosa is  turned  in.  There  is  nothing,  on  the  other  hand,  to  evert  the  mucosa 
again,  except  the  swelling  from  an  inflammation  which  tends  to  subside  after 
the  initial  stages  of  the  disease  have  passed. 

Symptoms. — The  symptoms  of  hydrosalpinx  are  variable.  When  there 
is  much  pain  and  soreness  in  the  pelvis,  this  is  usually  due  to  the  coincident 
pelvic  peritonitis  and  the  adhesions  formed.  The  pain  is  lateral,  on  one  or  both 
sides,  and  there  is  marked  tenderness  developed  on  pressure,  especially  if  the 
tube  is  squeezed  bimanually.  Upon  handling  the  tube  in  this  way,  the  patient 
is  often  able  to  locate  precisely  the  focus  of  her  discomforts. 

Backache,  bearing-down,  radiating  pains,  and  painful  defecation  are  symp- 
toms common  to  pelvic  inflammatory  disease  in  general. 

Menstruation  is  painful  in  over  50  per  cent  of  the  cases,  but  in  the 
remainder  it  is  in  no  way  affected. 

When  both  tubes  are  occluded  the  woman,  of  course,  remains  sterile; 
about  25  per  cent  of  my  cases  in  married  women  were  never  pregnant  at  all. 

When  one  tube  remains  patulous,  pregnancy  may  occur,  but  there  is  apt  to 
be  an  early  miscarriage  as  soon  as  the  enlarging  uterus  begins  to  make  traction 
on  the  unyielding  diseased  structure. 

Two  of  my  patients  who  had  no  children  became  pregnant  nine  and  five 
times  respectively  and  miscarried  every  time. 

It  must  be  borne  in  mind  in  studying  the  relationship  of  hydrosalpinx  to 
pregnancy  that  the  disease  often  makes  its  first  appearance  after  the  woman  has 
had  one  or  more  children. 

Diagnosis . — The  diagnosis  will  usually  be  made  best  by  emptying  the 
bowel  thoroughly  and  putting  the  patient  under  an  anesthetic.  Then  if  the 
bowel  is  inflated  with  air  by  placing  the  patient  for  a  short  time  in  the  knee- 
breast  posture  and  letting  air  in  through  the  anus,  a  minute  examination  of  the 
tubes  and  ovaries  can  be  made  and  any  abnormality  detected. 

Two  things  must  then  be  determined  :  first,  that  there  exists  a  cystic  enlarge- 
ment lateral  to  the  uterus,  but  not  directly  connected  with  it ;  and  second,  that 
the  ovary  is  not  the  seat  of  the  enlargement. 

A  hydrosalpinx  is  always  found  lateral  to,  or  lateral  and  posterior  to,  the 
uterus,  and  is  usually  elongate,  differing  in  this  respect  from  small  ovarian  cysts. 
If  its  curved  course  can  be  traced  and  one  or  more  kinks  made  out,  a  diagnosis 
may  be  made.     The  diagnosis  is  still  more  certain  when  the  ovary  is  carefully 


TUBO-OYARIAN    CYSTS.  207 

outlined  at  the  same  time  and  the  fact  made  sure  that  it  is  not  enlaro;ed.  When 
the  tube  and  the  ovarj  are  involved  in  much  surrounding  inflammation,  a  diag- 
nosis will  be  difficult  and  often  quite  impossible. 

The  distinction  between  hydrosalpinx  and  pvosalpinx  rests  upon  the  thick- 
ness of  the  tubal  walls  and  the  dense,  often  boardlike,  feeling  of  the  surround- 
ing peritoneal  and  cellular  tissue  engendered  by  the  suppuration. 

Treatment . — The  treatment  of  hydrosalpinx  and  its  associated  pelvic  in- 
flammation consists  in  the  adoption  of  measures  either  conservative  or  radical. 

The  conservative  plan  of  treatment  must  always  be  given  the 
precedence  in  young  women ;  this  has  been  dwelt  upon  in  detail  in  Chapter 
XXY,  and  in  brief  consists  in  breaking  uj)  adhesions,  either  by  the  rectum  or 
through  an  abdominal  or  vaginal  incision  ;  in  opening  and  making  a  new  ostium 
in  a  closed  tube ;  or  in  resecting  a  diseased  tube. 

It  must  be  remembered  that  no  matter  how  extensive  the  surrounding  in- 
flammation and  how  intimately  the  ovary  is  involved  in  it,  or  how  completely 
the  ovary  is  buried  in  adhesions,  this  organ  is  itself  rarely  diseased  and  rarely 
requires  removal.  A  chronic  ovaritis  does  not  exist,  and  the  cirrhotic  condition 
found  is  due  to  malnutrition  from  interference  with  the  circulation. 

The  only  possible  reason  for  removing  the  ovary  is  the  necessity  of  cutting 
short  the  menstrual  function. 

Radical  Treatment . — When  a  radical  plan  is  adopted  this  must  not 
be  done  as  a  routine  procedure,  but  only  after  deliberation  and  duly  weighing 
the  chances  of  conservatism  and  formulating  sufficient  reasons  for  the  extir- 
pation. 

The  radical  course  is  justified  in  a  young  woman  only  where  conservatism  has 
already  been  tried  and  has  failed,  and  in  older  women  who  are  condemned  by 
the  pelvic  disease  to  a  life  of  sufPenng  and  of  more  or  less  invalidism.  If  the 
woman  is  married  it  must  not  be  forgotten  that  even  after  forty,  women  have 
borne  children  under  the  most  discouraging  conditions.     (See  Chapter  XXY.) 

The  operation  consists  in — 

1.  The  removal  of  a  diseased  tube  alone,  or 

2.  The  removal  of  both  tubes  and  the  uterus,  leaving  the  ovaries,  or 

3.  The  removal  of  the  tube  and  the  ovary  together,  or 

4.  The  removal  of  uterus,  ovaries,  and  tubes. 

The  adhesions,  the  result  of  a  surrounding  pelvic  peritonitis,  vary  from  light 
bands  easily  severed  all  the  way  to  dense  inflammatory  masses  burying  the 
uterus  and  its  adnexa ;  these  must  be  carefully  and  deliberately  severed  under 
direct  inspection  until  the  pelvic  organs  are  set  perfectly  free. 

When  one  side  is  affected  the  best  plan  is  to  sever  all  adhesions  and  to  remove 
the  tube,  leaving  the  ovary.  This  may  he  done  by  lifting  up  the  tube 
with  its  mesosalpinx  and  viewing  it  by  transmitted  light,  by  which  the  vessels 
are  ])lainly  seen  grouped  principally  at  both  ends.  The  catgut  ligatures  may 
then  be  passed  through  the  mesosalpinx  and  tied  at  both  ends  so  as  to  include  the 
main  vessels ;  the  tube  is  then  stripped  off  by  cutting  close  under  its  peritoneal 
attachment.     The  edges  of  the  mesosalpinx  may  then  be  whipped  together  by  a 


208      SIMPLE    SALPINGO- OOPHORECTOMY    FOR    ADHERENT   TUBES    AND    OVARIES. 

fine  catgut  suture.  A  large  hvdrosalpmx  should  be  tapped  and  evacuated 
before  attempting  to  remove  the  tube. 

The  removal  of  a  tube  and  an  ovary,  or  of  both  tubes  and  ovaries,  is  only- 
done  in  order  to  check  menstruation  where  its  continuance  is  deemed  incom- 
patible with  complete  recovery ;  this  operation  is  tlie  same  as  that  of  simple 
salpingo-oophorectomy,  which  is  fully  described  in  the  first  section  of  this 
chapter. 

When  the  uterus  is  adherent  and  buried  in  the  inflammatory  disease  sur- 
rounding the  tubes  and  ovaries,  it  will  be  better  to  remove  this  organ  too,  in. 
the  manner  described  in  Chapter  XXVIII,  always  remembering  to  preserve 
the  ovaries  in  young  women,  if  possible. 


PLATE  XIV 


M.Brt)del,fec 


Lith.LPrang&CaBoslcn. 


DESCRIPTION  OF  PLATE  XIV. 

A  typical  pyosalpinx.  The  specimen  consists  of  a  deeply  injected  uterus  with  four 
small  subserous  myoniata,  and  a  distended  convoluted  characteristically  yellow  and 
injected  club-shaped  pyosalpinx  of  the  left  tube.  Note  the  injection  of  the  vessels  in 
marked  contrast  to  the  yellowish  appearance  of  the  tube. 

The  right  side,  in  precisely  similar  condition,  was  removed  a  few  weeks  before,  and 
the  left  tube,  thickened  and  inflamed,  but  Avithout  suppuration,  was  preserved  in  hope 
that  it  would  recover.  The  inflammatory  process  advanced,  however,  steadily  to  the 
condition  found  on  the  rig'ht  side,  and  the  tube  and  the  uterus  were  extirpated  at  the 
second  operation. 


Ill  aleaaov  siiJ  io  noiJ08J,ni  erU  ■■ 

.&{■:..     

pqorf  nr  bovio^eiq 
01 1 J  o)  Tlibe-iia  ,19/ 


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nli  oi  ifiinJnoo  I)9>lnBra 

I  ni  ,9[)"f8  ixf-gh  srfT 

Mt;  bfjcidiloidi  ,Q6ui  i\e[  edi 

(T    .levooei  bluow  ji  jBffJ 

;iT  arii  no  bnnol  noiJibfioo 

.noiJBiQqo  baooee 


CHAPTER  XXYIL 

VAGINAL   DRAINAGE   AND   ENUCLEATION  FOR  PYOSALPINX,  OVARIAN 
ABSCESS,   TUBO-OVARIAN   ABSCESS,    AND   PELVIC   ABSCESS. 

1.  Forms  of  abscess. 

2.  Causes  of  suppuration  :  1.  Gonococcus.    2.  Streptococcus.    3.  Staphylococcus  aureus  and  albus. 

4.  Micrococcus  lanceolatus.    5.  Bacillus  lactis  aerogenes.    6.  Proteus  Zeiikeri.    7.  Tubercle 
bacillus. 

3.  Table  showing:  bacteriological  examination  of  pus  from  ovaries  and  tubes. 

4.  Course  of  an  inflammatory  process. 

0.  Symptoms :  1.  Natural  terminations  of  an  abscess  by :  (a)  Discharge  through  uterus ;  (b)  dis- 
charge through  rectum,  vagina,  bladder,  abdominal  wall,  or  into  peritoneum ;  (c)  becoming 
encysted  ;  (d)  absorption  and  disappearance  of  pus. 

6.  Prognosis. 

7.  Diagnosis. 

8.  Treatment :  1.  Expectant.     2.  Emptying  the  sac  by  massage.     3.  Vaginal  incision  and  drain- 

age.   4.  Evacuation  through  the  rectum.    5.  Evacuation  liy  the  vagina  aided  by  an  abdomi- 
nal incision.     6.  Enucleation  of  pyosalpinx  and  ovarian  abscess  (salpingo-oophorectomy). 


Forms  of  Abscess. — The  term  "  pelvic  abscess "  as  used  in  gvnecologv  is 
somewhat  vague,  for  while  it  hterallj  inchides  all  forms  of  pus  accumulations 
found  in  any  part  of  the  pelvis,  from  the  tip 
of  the  vermiform  appendix  to  the  ischio-rec- 
tal  fossa,  common  usage  has  restricted  it  to 
intrapelvic  suppurations  in  the  neighborhood 
of  the  uterus.  Considerable  confusion  exist- 
ed for  many  years  as  to  the  actual  site  of 
these  abscesses ;  it  was  long  supposed  that 
they  w'ere  all  alike  located  in  the  cellular 
tissue,  and  were  the  outcome  of  a  cellulitis. 
As  a  matter  of  fact,  demonstrations  made 
fi'om  hundreds  of  cases  minutely  observed 
during  the  last  decade  prove  that  the  seat 
of  the  abscess,  as  a  rule,  is  located  in  the  uterine  tube  or  the  ovaiw,  and 
that  it  is  rarely  found  in  the  cellular  tissue. 

I  have  found  accumulations  of  pus — 

1.  Encapsulated  in  one  or  both  uterine  tubes — pyosalpinx,  single  and  double. 

2.  Within  the  ovary — ovarian  abscess. 

3.  In  tulte  and  ovary  sej)arately — tubal  and  ovarian  abscess. 

4.  In  tube  and  ovary  combined  into  a  common  abscess  cavity — a  tul)0-ovarian 
abscess. 

5.  In  the  cornu  uteri — cornual  abscess. 

209 


Fig.  382. — Ottline  of  the  Tor.'ion  of 
THE  Pyosalpinx  shown  in  the  Col- 
oKED  Plate. 

The  axis  is  shown  by  a  dotted  line  which 
is  heavier  or  lifflitcr  aecorcUug  as  its  plane 
lies  nearer  or  farther  from  the  observer. 
Nov.  9,  1894. 


210  YAGIXAL    DRAINAGE   AXD    ENUCLEATION    FOR    PYOSALPINX,    ETC. 

6.  On  the  floor  of  the  pelvis  below  the  utero-sacral  folds — abscess  of  Doug- 
las's cul-de-sac. 

7.  Anterior  to  the  uterus  in  the  cellular  tissue,  as  well  as  in  the  uterine  tube. 

8.  In  and  about  a  vermiform  ajjpeudix  hanging  down  into  the  pelvis — sup- 
purative appendicitis, 

9.  Al)Out  the  vermiform  appendix  and  in  the  uterine  tube  at  the  same  time. 

10.  Between  adherent  coils  of  intestine  in  the  pelvis. 

11.  About  the  pedicle  left  after  an  abdominal  operation. 

12.  In  suppurating  ovarian  and  dermoid  cysts. 

Abscesses  are  also  found  (13)  in  the  uterine  walls  and  (14)  in  the  cellular  tis- 
sue at  the  bases  of  the  broad  ligaments. 

Causes  of  Suppuration. — Suppurative  affections  of  the  pelvic  organs  are  due 
to  any  of  the  pus-producing  micro-organisms  which  usually  find  their  entrance 
through  the  vagina  into  the  uterus,  and  then  into  the  pelvis,  either  by  way  of 
the  uterine  tube  or  by  the  lymphatics  through  the  uterine  wall  and  parametrium. 
The  route  of  extension  from  the  uterus  depends  largely  upon  the  variety  of  the 
organism ;  the  gonococcus  almost  always  travels  along  the  mucous  membrane 
into  the  tube,  where  its  further  extension  may  be  arrested  and  the  reactionary 
inflammation  confined  to  the  tube,  or  it  may  escape  onto  the  pelvic  peritoneum, 
setting  up  a  localized  peritonitis. 

In  gonococcal  infection  the  inflammatory  process  is  almost  invari- 
ably confined  to  the  pelvic  organs  and  their  immediate  environment,  rarely  caus- 
ing more  than  a  local  reaction,  and  never  giving  rise  to  a  general  infection.  In  a 
number  of  cases  I  have  been  able  to  trace  the  course  of  the  progressive  steps  of 
the  invasion  of  the  gonococcus  all  the  way  from  the  external  genitals  to  the 
pelvic  organs. 

In  one  instance  where  a  patulous  fimbriated  extremity  of  a  tube  was  seen 
with  the  pus  containing  gonococci  escaping  into  the  pelvic  cavity,  at  the  time  of 
operation  for  the  removal  of  the  tubal  abscess,  gonococci  were  also  demon- 
strated in  the  free  pus  in  tlie  abdomen,  in  the  uterine  tube,  in  the  uterus,  the 
vagina,  in  Bartholin's  glands,  in  Skene's  tubules,  and  in  the  urethra,  making  the 
chain  of  the  infection  complete. 

Besides  the  extension  of  gonococcus  infection  along  the  mucosa,  it  has  been 
shown  (Wertheim)  that  it  may  also  pass  into  the  submucous  connective  tissue 
and  even  enter  the  circulation.  Many  writers,  and  especially  E.  JS^oeggerath, 
Sanger,  and  A.  v.  Rosthorn,  lay  great  stress  upon  the  frequency  of  pyosalpinx 
due  to  the  gonococcus.  The  two  latter  found  tubal  disease  in  33  per  cent  of 
all  women  affected  with  gonorrhea.  While  the  cultures  taken  from  the  pus 
in  these  cases  frequently  do  not  show  its  presence,  I  am  constrained  to  attrib- 
ute this  failure  to  defective  culture  methods  rather  than  to  the  absence  of 
this  germ,  because  cover-glass  prej^arations  frequently  show  diplococci  which 
resemble  gonococci,  and  the  clinical  history  of  the  cases  points  strongly  in  this 
direction . 

Gonococci  have  been  found  in  ovarian  abscesses  by  Wertheim,  Sanger,  and 
Zweifel. 


CAUSES    OF   SUPPURATIOX.  211 

The  history  of  a  streptococcus  infection  is  different  from  that  of 
the  gonococcus,  both  in  its  cHnical  course  and  in  the  route  of  its  extension. 

Infection  from  this  organism  usually  occurs  during  a  badly  conducted 
puerperium,  or  after  an  abortion,  or  is  introduced  into  the  uterus  by  dirty 
instruments  in  the  hands  of  the  physician.  Intra-uterine  applications,  and 
the  introduction  of  sounds  and  dilators  without  proper  antiseptic  precautions, 
are  among  the  commonest  means  of  conveying  the  infection  from  patient  to 
patient. 

When  stre]3tococci  gain  entrance  to  the  uterus  they  may  invade  the  pelvis  by 
the  same  route  as  the  gonococci,  or  they  may  penetrate  the  uterine  wall,  setting 
up  an  endometritis  or  metritis,  and  then  a  parametritis,  forming  a  more  or  less 
dense  swelling,  occurs  which  usually  terminates  in  an  indurated  phlegmon  or  a 
pelvic  cellular  abscess. 

The  tube  and  ovary  may  then  be  involved  by  continuity  or  by  blood  infec- 
tion, or  they  may  escape  infection  and  lie  upon  the  top  of  the  abscess  intact. 

The  staphylococcus,  while  comparatively  rare,  is  occasionally  obtained 
from  pelvic  abscesses. 

E.  Raymond  and  W.  S.  Magill,  in  a  careful  bacteriological  study  of  salpingo- 
oophoritis,  while  not  denying  the  possibility  of  staphylococcus  infection,  say  that 
they  have  never  seen  it.  K.  Menge  reports  one  case  in  a  series  of  twenty-six  bac- 
teriological examinations,  Y.  Morax  one  in  thirty-three  cases,  while  F.  Schauta  has 
only  seen  the  streptococcus  and  the  staphylococcus  four  times  in 
one  hundred  and  forty-four  cases. 

Wertheim  found  in  116  cases  of  pyosalpinx  that  72  times  there  were  no  bac- 
teria at  all,  32  times  there  were  gonococci,  0  times  streptococci,  and  once  staphy- 
lococci. 

In  twenty-five  eases  of  pelvic  abscess  opened  through  the  vagina  in  my  clinic, 
Dr.  G.  B.  Miller  found  the  staphylococcus  aureus  twice  and  the  a  1  b u  s 
twice.  In  a  series  of  forty -three  cases  of  purulent  conditions  of  the  ovaries  and 
tubes  one  case  showed  a  mixed  infection,  consisting  of  the  staphylococcus 
a  1  b u s  and  a u r e u s  and  the  streptococcus.  Pelvic  abscesses  may  also 
be  due  to  a  colon  bacillus  infection. 

Among  the  rarer  organisms  found  are  the  micrococcus  1  a  n  c  e  o  1  a  t  u  s , 
the  bacillus  lactis  aero  genes,  and  the  proteus  Zenkeri.  Tu- 
bercle 1)  a  c  i  1 1  i  are  occasionally  found  in  the  walls  of  pehac  abscesses. 

In  the  twenty -five  cases  of  pelvic  abscess  evacuated  j;<?r  vaginam  in  my  clinic 
the  cultures  were  negative  in  twelve  cases,  streptococci  were  found  in  three 
cases,  the  colon  l)acilliis  four  times,  staphylococcus  pyogenes  aureus  in  two  cases, 
staphylococcus  pyogenes  albus  in  two  cases,  and  the  gonococcus  in  four  cases. 

In  two  cases  only  were  the  gonococci  grown  on  culture,  the  other  two  being 
determined  from  cover-glass  preparations. 

In  a  careful  bacteriological  examination  of  forty-three  cases  of  pyosalpinx, 
ovarian  abscess,  and  pelvic  abscess,  removed  through  the  abdominal  incision,  or- 
ganisms were  found  much  less  frequently  than  in  the  above-mentioned  cases, 
which  gives  ground  for  the  suspicion  that  the  cultures  taken  by  the  vaginal 


212 


VAGINAL    DRAINAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 


puncture  may  have  been  contaminated.    The  results  of  the  examination  of  these 
forty-three  cases  are  summarized  in  the  following  table : 

Table  shoiving  Bacteriological  Examination  of  Pus  from  Ovaries  and  Tubes. 


Diagnosis. 

Cover-glass.               Agar. 

Glycerin  agar. 

Acid 
gelatin. 

Blood 
serum. 

Bacteria. 

1 

Pyosalpinx. 

Negative. 

Negative. 

Negative. 

Negative. 

2 

" 

Diplococci  in 

cells. 
Diplococci  free 

" 

Gonococci. 

3 

(i 

a 

and  in  pns  cells. 

4 
5 
6 

*' 

Negative. 

Negative. 

Pelvic  ab- 

" 

" 

'• 

scess. 

7 
8 
9 

Pyosalpinx. 

" 

" 

tl 

" 

" 

Nega- 

" 

tive. 

10 

" 

*' 

" 

Do. 

Nega- 
tive. 

" 

11 

" 

" 

'• 

Do. 

Do. 

" 

12 

Salpingitis. 

" 

" 

Do. 

Do. 

" 

13 

Pyosalpinx. 

" 

" 

Do. 

Do. 

'• 

14 

Pink  yeast. 

Pink 
yeast. 

Pink 
yeast. 

Pink  yeast,  con- 
tamination of 
culture  tubes. 

15 

Ovarian  ab- 
scess. 

" 

Negative. 

Negative. 

Negative. 

16 

Pyosalpinx. 

'* 

Nega- 
tive. 

Nega- 
tive. 

** 

17 

Pelvic  ab- 
scess. 

" 

*' 

Do. 

Do. 

" 

18 

Pvosalpinx. 

" 

" 

" 

19 

" 

ii 

it 

" 

20 

*' 

Diplococci  in 
cells. 

a 



Gonococci. 

21 

" 

Negative. 

a 

Negative. 

22 

Diplococci  in 
cells. 

Gonococci. 

23 

'* 

Negative. 

" 

Nega- 
tive. 

Nega- 
tive. 

Negative, 

24 

" 

" 

Do. 

Do. 

" 

25 

" 

'• 

" 

Do. 

Do. 

" 

26 

" 

(k 

" 

Do. 

Do. 

" 

27 

u 

" 

" 

Do. 

Do. 

" 

28 

" 

" 

" 

Do. 

Do. 

" 

29 

" 

" 

Do. 

Do. 

30 

Ovarian  ab- 
scess.* 

Resembling 
colon  bacillus. 

A  white  colony. 

Undiagnosed. 

31 

Pyosalpinx. 

Negative. 

Negative. 

Negative. 

3'^ 

u 

" 

33 

Negative. 

" 

34 

" 

'• 

" 

' 

35 

" 

'< 

•' 

36 

ii 

Gonococci. 

" 

" 

Nega- 
tive. 

Gonococci. 

37 

" 

Negative. 

" 

Do. 

Negative. 

38 

" 

'• 

" 

•' 

39 

" 

" 

" 

" 

40 

" 

Gonococci. 

" 

Gonococci. 

41 

" 

Negative. 

" 

*  On  lactose  agar,  a  white  growth  resembling  that  in  glycerin  agar.     No  gas  fermentation ; 
also  a  delicate  granular  growth  which  liquefies  gelatin. 


COURSE    OF   AN    INFLAMMATORY    PROCESS. 


213 


Diagnosis. 

Cover-glass. 

Agar. 

Glycerin  agar. 

Acid 
gelatin. 

Blood 
serum. 

Bacteria. 

42 
43 

Pyosalpinx. 

Many  cocci  in 
pairs  and  chains. 

Diplococci  in 

pairs ;  extra-  and 

intra-cellular. 

.Staphylo. 
pyog.  aure- 
us and 
albus, 
strepto. 

Gonococci. 

Staphylococcus 
albus  and  aure- 
us, strepto- 
coccus. 

Gonococci. 

Total. 

Negative 33  cases. 

Gonococcus 7     " 

Colon  bacillus 0 

Mixed  infection,  staphylococcus  albus  and  aureus  and  streptococcus 1  case. 

Undiagnosed 1      " 

Contaminated 1      '" 


On  account  of  tlie  close  proximity  of  the  pelvic  organs  to  the  rectum,  vermi- 
form appendix,  and  sigmoid  flexure,  pyogenic  bacteria  may  escape  from  one  to 
the  other  and  set  up  a  purulent  inflammation.  Dr.  Hunter  Kobb  has  reported 
a  case  in  which  the  pus  of  a  pyosalpinx  of  one  side  gave  negative  results  on  bac- 
teriological examination,  while  an  inflamed  tube  on  the  other  side,  adherent  to  an 
acutely  inflamed  vermiform  apj^endix,  contained  streptococci. 

Mixed  infections  of  two  or  more  different  micro-organisms  are  rarely  found. 
An  organism  may  develop  a  pelvic  abscess  and  die  and  pave  the  way  for  the 
secondary  invasion  by  bacteria  of  another  form. 

Course  of  an  Inflammatory  Process. — Tlie  flrst  effect  of  the  entrance  of  the 
infecting  organism  into  the  uterine  tube  is  to  set  up  a  reactionary  inflammation 
which,  as  a  rule,  tends  to  close  the  fimbriated  end.  In  mild  cases  the  inflamma- 
tory condition  may  pass  off  without  the  production  of  a  pyosalpinx  ;  when  the 
infection  is  more  severe,  pus  forms  in  the  tube  and  may  discharge  into  the 
uterus,  or  the  fimbriated  end  may  rupture  and  permit  the  escape  of  pus  into 
the  pelvis  over  the  ovary,  producing  peri-oophoritis  and  pelvic  peritonitis,  if  it  is 
a  gonococcal  infection  ;  or  a  general  peritonitis,  if  more  virulent  j^us-producing 
organisms  are  present.  The  inflammatory  condition  may  be  arrested  in  the 
uterine  tube,  but  if  the  infection  is  persistent  it  may  involve  the  intraligamentary 
cellular  tissue. 

The  ovary  is  usually  involved  in  the  surrounding  inflammatory  condition 
(peri-oo))horitis),  and  only  rarely  is  the  seat  of  an  ovarian  abscess.  Infection  of 
tlie  ovary,  when  it  does  occur,  probably  takes  place  through  a  ruptured  Graafian 
follicle. 

In  one  of  my  cases  (see  Fig.  384),  like  one  described  by  Sanger,  the  abscess 
was  situated  deep  in  the  substance  of  the  ovary,  and  there  was  no  coincident 
tubal  infection. 

The  initial  stages  of  salpingitis  are  associated  with  a  more  or  less  violent 
local  reaction,  in  which  the  tubes  become  thickened  and  edematous  and  fall  back 
in  the  pelvis  down  toward  the  pelvic  floor.  The  mucosa  becomes  congested 
and  swells,  and  is  bathed  in  a  mucoid,  semi-purulent,  or  purulent  secretion. 


214 


YAGINAL    DKAIXAGE    AXD    ENUCLEATION    FOR    PYOSALPIXX,    ETC. 


The  reactionary  inflammation  from  contisjmty  of  tissues  causes  the  tubes  to 
become  adherent  by  light  adhesions  to  the  adjacent  organs.  As  the  inflamma- 
tory process  progresses  the  adhesions  become  more  dense,  and  flnally  the  tube 
becomes  closely  attached  to  the  posterior  surface  of  the  broad  ligament,  to  the 


Fig.  383. — Large  Absckss  of  the  Kigiit  Ovary,  without  Participation  of  the  Tube,  due  to  Staphylo- 
coccus Aureus  Infection. 

The  areas  of  denser  adhesions  are  indicated  by  the  bits  of  tissue  attached  to  the  abscess.  The  tube  is 
buckled  on  itself  and  iixed  by  an  isthniio-ampullar  adhesion.  View  from  behind.  June  1,1894.  No.  317. 
Natural  size. 

uterus,  the  pelvic  wall  and  floor,  and  covers  in  the  ovary  with  its  mesosalpinx. 
The  rectum  is  more  especially  liable  to  be  involved  in  the  adhesions  when  the 
inflammation  is  in  the  left  tube. 

The  pus  varies  in  appearance  from  a  thin  puriform  fluid  to  thick  yellow 
matter  ;  it  may  be  greenish  and  streaked  with  blood  ;  sometimes  it  is  intensely 
fetid,  with  a  strong  odor  of  garlic.  This  is  apt  to  be  the  case  when  the  ab- 
scess lies  in  close  proximity  to  the  rectum.  Both  tubes  and  ovaries  may  con- 
tain pus  and  only  one  of  them  smell  badly. 

As  a  rule,  both  sides  are  affected,  but  the  abscess  on  one  side  is  usually 
larger  than  on  the  other.  Occasionally,  however,  one  side  presents  an  advanced 
pyosalpinx  and  its  fellow  is  sound.     This  liability  of  both  sides  to  share  in  the 


SYMPTOMS. 


215 


disease  shows  that  there  is  a  definite  tendency  in  the  progression  of  the  disease 
from  without  inward. 

The  term  s  a  c  t  o  s  a  1  p  i  n  x  is  appHed  to  closed  tubes,  and  according  as  the 
contents  are  watery,  bloody,  or  purulent,  the  disease  is  denominated  as  a 
saetosaljsinx  serosa,  hemorrhag- 
i  c  a,  or  purulent  a.  When  the  tube  pre- 
sents a  nodular  appearance  from  separate 
accumulations  in  the  isthmns,  the  affection  is 
termed  a  salpingitis  isthmica  no- 
dosa. This  form  of  salpingitis  is  most  fre- 
quently seen  in  gonorrheal  affections  (see 
Fig.  3S5). 

Symptoms. — The  symptoms  produced  by 
the  presence  of  pus  in  the  ovaries,  tubes, 
and  surrounding  pelvic  tissues  vary  widely 
according  to  the  stage  of  the  disease  and  to 
the  variety  of  infecting  organisms.  During 
the  acute  stage,  lasting  a  week  or  longer,  the 

patient  often  suffers  intense  pain  ;  she  lies  in  bed  ^vith  knees  drawn  up  and  an 
anxious  expression  of  face.  The  elevated  temperature,  quickened  pulse,  and 
local  tenderness  all  point  to  an  inflammation  localized  in  the  pelvis.  From  the 
general  tenderness  and  tympany  often  present,  the  physician,  however,  is  apt  to 
draw  the  erroneous  conclusion  that  there  is  a  general  jjeritonitis. 

In   gonorrheal   cases   the   pelvic  inflammation   may  be  preceded  by 
an  acute  inflammation  of  the  urethra,  vulva,  and  vagina,  which  may  then  be 


Fig.  384. —  Abscess  of  the  Ovary  Deep 
DOWN  IX  THE  Center,  Cokpls  Nigrum 
AND  Corpus  Luteum  and  Corpora  Fi- 
brosa IN  THE  Surrounding  Capsule  of 
Ovarian  Substance.  March  29,  1894. 
Natural  Size. 


Fig.  385. — Nodular  Salpingitis,  Salpingitis  Isthmica  Noi.. ..--a. 
Found  oftun  in  gonorrlieal  salpingitis,  and  in  some  tubercular  forms.    Feb.  24, 1894.     Natural  size. 


quickly  followed  by  pelvic  pains  and  high  fever ;  the  pelvic  symptoms,  on 
the  other  hand,  may  be  deferred  for  several  days  or  months  after  the  primary 
infection,  when  the  causal  relation  is  not  so  evident.  The  onset  may  then  be 
gradual,  beginning  with  the  acute  pain  in  the  ovarian  regions,  a  slight  rise  of 


216  VAGINAL    DRAINAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 

temperature,  and  painful  micturition  and  defecation.  After  pus  lias  formed  the 
patient  may  have  rigors,  but  this  is  not  so  frequent  as  in  the  graver  types  of  in- 
fection. The  pulse  is  good,  there  is  little  or  no  vomiting,  the  expression  is  that 
of  a  person  suifering  with  pain,  but  the  general  condition  is  excellent. 

In  a  streptococcus  infection  the  attack  often  dates  from  a  con- 
finement, an  abortion,  or  local  treatment  of  the  uterus.  The  onset  is  rapid  and 
attended  by  a  chill,  high  fever,  and  a  rapid  pulse.  The  effect  of  the  septic  ab- 
sorption is  soon  shown  in  the  general  depression ;  the  expression  is  bad,  the 
pulse  becomes  more  rapid,  and  the  abdominal  distention  and  tenderness  is 
marked.  In  the  strej^tococcus  cases  the  patient  is  bedridden  from  the  begin- 
ning of  the  attack,  while  the  patient  with  a  gonorrheal  infection  may  only  be 
bedridden  a  week  or  ten  days  or  not  at  all. 

After  the  acute  attack  has  passed  in  both  the  gonorrheal  and  strej)tococcu8 
infections  the  patient  may  get  out  of  bed,  continuing  to  suiter,  but  in  the  strep- 
tococcus cases  she  usually  has  a  septic  temperature  and  the  peculiar  anemic  look 
of  a  grave  infection. 

The  attacks  of  pain  and  of  localized  peritonitis  tend  to  recur  at  variable  in- 
tervals, and  are  attended  each  time  with  the  same  symptoms,  which  may  con- 
tinue until  a  large  abscess  has  formed  behind  the  uterus  on  one  or  both  sides, 
completely  filling  the  posterior  pelvis. 

Obstinate  constipation  is  sometimes  found  as  a  result  of  the  pain 
on  straining  at  stool,  or  due  to  a  stricture  of  the  rectum  produced  by  the  in- 
flammatory mass  bridging  its  lumen.  In  cases  of  long  standing  the  stricture  may 
even  become  so  narrow  as  to  form  a  serious  obstacle  in  securing  the  evacu- 
ations. This  condition  was  found  five  times  in  sixty-five  cases  of  pelvic  in- 
flammatory disease  treated  by  vaginal  incison  in  my  clinic. 

Frequent  urination  is  often  distressing  and  may  arise  from  impli- 
cation of  the  bladder  and  of  one  or  both  ureters  in  the  inflammatory  mass. 
Sometimes  there  is  an  actual  cystitis  from  an  infection  of  the  bladder  similar  to 
that  existing  in  the  tubes  and  ovaries. 

After  the  acuter  symptoms  have  subsided  the  patient  is  left  weak,  wan,  and 
sallow,  looking  as  if  she  had  survived  a  severe  illness  ;  she  is  relaxed,  perspires 
profusely  upon  slight  exertion,  and  can  not  walk  without  distress.  The  tempera- 
ture drops  a  little,  but  often  does  not  fall  to  normal  for  some  days  or  weeks, 
rising  to  99°  or  100°  F.  in  the  evening.  There  is  often  also  a  persistent  fixed 
pain  in  the  lower  abdomen. 

Sometimes  the  symptoms  gradually  abate,  and  the  patient  finally  regains 
complete  health.  In  such  cases  there  is  often  little  or  no  evidence  of  the  previ- 
ous inflammatory  disease  found  on  a  careful  examination,  or  again  the  append- 
ages may  be  found  adherent  but  without  any  evidence  of  suppuration. 

If  the  pelvic  suppuration  persists,  the  symptoms,  although  less  severe  than 
in  the  acute  process,  are  always  present ;  the  patient  complains  of  bearing-down 
pain,  backache,  painful  defecation  and  micturition,  and  often  of  a  purulent 
vaginal  discharge.  The  gonococcal  infection  is  most  likely  to  subside  in  this 
way. 


SYMPTOMS.  217 

A  sudden  elevation  of  the  temperature  durino-  an  attack  is  always  a  serious 
symptom,  denoting  an  extension  of  the  inHammatory  trouble,  a  grave  septicemia, 
or  a  general  peritonitis.  In  chronic  cases  the  patients  may  suffer  for  twenty 
years  or  more  from  such  recurring  attacks. 

If  the  abscess  is  not  interfered  with,  one  of  four  modes 
of   termination   maybe   observed: 

1.  It  may  discharge  intermittently  through  the  uterus. 

2.  It  may  rupture  and  evacuate  itself  by  the  rectum,  by  the  vagina,  by  the 
bladder  or  by  the  abdominal  wall,  or  it  may  discharge  into  the  peritoneal  cavity. 

3.  The  pus  may  remain  encysted  for  an  indefinite  period  and  small  accumu- 
lations may  become  inspissated. 

4.  It  may  entirely  disappear,  leaving  behind  a  hydrosalpinx,  or  contracted 
tubes  and  ovaries  bound  down  and  enveloped  in  adhesions. 

In  a  pelvic  abscess  which  goes  on  to  rupture  the  process  is  usually  an 
acute  one  throughout,  running  its  course  with  high  fever,  much  pain,  and  tym- 
pany, and  ending  in  the  formation  of  a  large  pus  sac  which  points  into  the  vagi- 
nal vault  posterior  to  the  cervix,  or  into  the  rectum,  or  works  its  way  up  under 
the  lateral  wall  of  the  pelvis,  appearing  on  the  anterior  abdominal  wall  above 
Poupart's  ligament. 

Occasionally  the  bladder  is  perforated  and  a  large  amount  of  pus  suddenly 
escapes  by  the  urethra. 

In  rare  cases  the  abscess  ruptures  through  the  vaulted  free  surface  of  the 
sac  and  the  pus  is  poured  into  the  abdominal  cavity,  escaping  among  the  free 
intestines  and  bathing  the  whole  abdomen.  It  may,  however,  be  limited  in  its 
distribution  by  the  coils  of  distended  intestines  which  adhere  to  the  sac  so  as  to 
shut  it  off  from  the  general  peritoneal  cavity. 

The  symptoms  following  this  accident  will  depend  upon  the  character  of  the 
pus.  In  the  more  \drulent  cases  the  patient  will  at  once  fall  into  a  condition  of 
collapse,  with  rapid,  thready  pulse,  Avhich  fails  to  respond  to  any  stimulation  ; 
she  lies  apathetic,  with  a  lack  luster  look,  and  dies  in  two  or  three  days.  In 
another  class  of  cases,  on  the  other  hand,  the  discharge  of  even  250  cubic  centi- 
meters (^  pint)  of  pus  into  the  abdomen  may  be  followed  by  a  slowly  developing 
peritonitis,  with  elevation  of  temperature,  and  a  pulse  rising  slowly  to  120,  140, 
and  160. 

Abscesses  which  open  into  the  vagina  may  discharge  their  contents  com- 
pletely and  the  cavity  collapse  and  heal,  and  tlie  patient  regain  perfect  health. 

If  the  opening  is  minute  through  a  fistulous  tract  the  discharge  only  takes 
place  when  there  is  sufiicient  pressure  within  to  overcome  the  resistance,  and  it 
may  continue  in  this  way  for  months  or  years,  each  reaccumulation  being  char- 
acterized by  a  return  of  pain,  fever,  and  distention.  In  some  cases  the  hole 
cicatrizes  over  and  breaks  open  afresh  each  time. 

AVlien  the  abscess  opens  into  the  rectuui,  if  the  opening  is  direct  and  large 
enough  and  lies  at  the  bottom  of  the  sac,  a  rapid  and  complete  recovery  may 
take  place.  If,  on  the  other  hand,  the  abscess  empties  into  the  bowel  by  a  long 
sinus  or  by  a  minute  orifice,  or  if  the  opening  is  in  the  upper  part  of  the  ab- 


218  VAGINAL    DRAINAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 

scess,  SO  that  the  pus  only  discharges  when  the  sac  is  full,  the  discharge  may 
go  on  indefinitely. 

A  pehdc  abscess  opening  into  the  bladder  or  onto  the  abdominal  wall  rarely 
closes,  because  the  opening  lies  at  a  higher  level  than  the  sac,  and  pus  can  there- 
fore only  escape  as  an  overflow  or  in  certain  positions  of  the  body ;  these  open- 
ings are  also  always  indirectly  connected  with  the  sac  by  a  sinus  which  may 
pursue  a  long,  tortuous  course  before  reaching  the  abdominal  wall. 

Prognosis. — The  symptoms,  course,  and  termination  of  these  ..pel  vie  inflam- 
matory affections  dejjend  upon  the  species  and  the  virulence  of  the  infecting 
organisms. 

Gonorrheal  pyosalpinx  usually  expends  its  force  upon  the  uterine  tube, 
and  beyond  the  peri-oophoritis  and  pelvic  peritonitis  produced  by  the  irritant 
effects  of  the  toxic  products  elaborated  by  the  organisms  no  more  extensive 
damage  occurs.  The  inflammatory  condition,  however,  may  be  chronic,  lasting 
for  years,  and  is  often  characterized  by  exacerbations. 

In  streptococcus  or  staphylococcus  infections  the  course  of  the  disease  is  more 
rapid,  tending  to  produce  a  general  peritonitis  or  septicemia.  While  a  consid- 
erable percentage  of  streptococcus  cases  die,  many  survive,  but  are  often  inca- 
pacitated by  the  accumulation  of  pus  or  by  the  extensive  and  widespread  adhe- 
sions remaining  after  the  inflammatory  condition  has  subsided.  In  about  half 
the  chronic  cases  the  organisms  die  and  the  pus  becomes  sterile. 

The  prognosis  is  always  serious,  and  a  patient  with  a  pelvic  abscess  is  never 
out  of  danger,  but  lives  literally  over  a  mine  which  may  explode  at  any  time, 
when  only  the  most  prompt  interference  can  save  life. 

Diagnosis. — The  diagnosis  of  an  abscess  involving  the  uterine  tubes  or  the 
ovaries,  or  both,  is  often  easy  to  make.  One  of  the  chief  points  in  establishing 
it  may  be  the  history  of  an  attack  of  gonorrhea,  a  septic  labor,  or  miscarriage, 
since  which  time  the  j^atieiit  has  never  enjoyed  good  health  ;  many  patients  will 
recall  a  confinement  to  bed  for  one  or  more  weeks  with  peritonitis. 

Many  others  date  their  ill  health  from  the  first  or  second  month  after  mar- 
riage, even  going  back  to  the  very  week  of  the  marriage,  and  recalling  a  more 
or  less  profuse  irritating  leucorrheal  discharge  with  swelling  of  the  internal 
genitals  and  dysuria.  The  outbreak  of  pelvic  peritonitis  may  then  take  place  at 
the  first  menstrual  period  after  marriage.  Careful  questioning  of  the  husband 
in  these  cases  will  often  elicit  the  information  that  he  was  suffering  from  a 
slight  gleety  discharge  at  the  time.  The  husband  of  one  of  my  patients  actually 
had  a  swelled  testicle  on  his  wedding  day.  It  is  IS^oeggerath's  opinion  that  no 
man  who  has  had  gonorrhea  is  ever  cured  of  it. 

In  other  cases  there  is  no  such  definite  history  of  an  .initial  attack  and  no 
sharp  line  of  demarkation  between  health  and  disease ;  the  onset  is  gradual,  the 
pains  growing  worse  and  worse  with  each  menstrual  period,  until  a  status  of 
invalidism  is  finally  reached. 

Following  the  initial  symptoms,  the  most  characteristic  features  in  the  natu- 
ral history  of  the  disease  are  attacks  of  peritonitis,  confining  the  patient  to 
bed  for  da,ys,  weeks,  or  months,  often  referred  to  as  "  inflammation  of  the 


DIAGNOSIS.  219 

stomach."  The  patient  will  often  recall  that  her  life  was  even  despaired  of  at 
this  time. 

The  general  appearance  of  a  patient  suffering  from  an  abscess  of  the 
appendages  varies  from  a  look  of  complete  health  to  marked  emaciation,  a  sallow 
complexion,  and  an  expression  of  constant  suffering. 

Her  attitude  and  gait  as  she  enters  the  room  are  often  significant ; 
there  is  a  slight  bending  of  the  body  over  the  pelvis,  a  cautious  gait,  and  a  habit 
of  placing  the  hands  on  the  lower  abdomen,  keeping  up  an  even  pressure  on  the 
pelvic  viscera  to  avoid  jarring  them.  This  effort  is  especially  marked  in  step- 
ping over  a  gutter  in  crossing  the  street.  I  have  known  a  woman  to  wear  a 
shawl  whenever  she  went  out  to  hide  these  efforts  and  the  position  of  her  hands. 

The  differential  points  in  the  diagnosis  between  gonorrheal  and  streptococcus 
cases  may  be  summarized  as  follows : 

Gonorrheal  Ixfectiox.  Streptococcus  Infectiox. 

Slow  in  its  onset,  often  preceded  by  inflarama-  Onset    abrupt,   following    miscarriage,  normal 
tion  of  the  external  genitals  and  urethra.  labor,  or  topical  treatments. 

Pain  localized  in  one  or  both  ovarian  regions.  Pain  more  general  and  severe  in  the  lower  abdo- 
men. 

No  signs  of  general  peritonitis.  Usually  signs  of  peritonitis. 

Suffers  more  or  less  constantly,  but  may  have  Suffers  constantly,  and  usually  has  a  septic  fever, 
no  fever. 

Temperature  98-5°  to  103'  F.  (38-9"  C).  Temperature  lOr  to  105'  F.  (38-3°  to  40-5''  C). 

Pulse  accelerated,  but  of  good  quality  and  vol-  Pulse  feebler  and  moi'e  rapid, 
ume. 

Attack  lasts  five  to  fifteen  days.  Attack  seldom  lasts  less  than  a  month,  and  may 

continue  three  months  or  more. 

Often  presents  the  appearance  of  good  health.  Anemic  and  weak. 

Gonococci  usually  found  in  cover-slip  prepara-  Gonococci  not  found  in  the  secretions, 
tions  fi'om  the  cervical,  urethral,  or  vulvo- 
vaginal glandular  secretions. 

History  of  marital  gonorrhea.  Husband  sound. 

A  vaginal  examination  shows  that  the  uterus  has  lost  its  natural  mobility , 
sometimes  it  is  solidly  wedged  in  between  masses  which  are  felt  on  one  or  both 
sides  of  the  cervix  as  dense,  hard,  shapeless,  resisting  bodies.  A  stony  hard- 
ness of  tlie  vaginal  vault  is  one  of  the  most  characteristic  signs  of  the  presence 
of  pus.     The  position  of  the  fundus  often  can  not  be  located  amid  these  masses. 

The  bimanual  examination  does  not  at  first  definitely  outline  any 
diseased  organs,  but  simply  confirms  the  discovery  made  by  the  vaginal  hand, 
that  the  pelvic  peritoneal  fioor  has  become  dense  and  resisting,  and  that  the 
posterior  pelvis  is  choked  with  irregular  masses. 

A  continued  careful  palpation  l)y  a  trained  hand,  however,  will  soon  succeed 
in  differentiating  several  groups  of  bodies  in  the  ])elvis  by  their  location  and  rela- 
tive mobility.  The  first  landmark  to  be  established  is  the  body  of  the  womb. 
This  is  done  l)y  pushing  u])<»n  the  cervix  with  the  vaginal  finger  and  making 
deep  pressure  from  above  until  an  impulse  is  feU  at  the  cervix  ;  in  tliis  way  the 
fundus  can  be  traced  by  its  direct  continuity  with  the  cervix,  either  in  front  of 
it  or  behind  it.    The  limit  of  motion  in  the  fixed  uterus  is  small,  sometimes  only 


220  VAGINAL    DRAINAGE    AND    ENUCLEATION    FOR   PTOSALPINX,    ETC. 

a  few  millimeters,  but  it  can  be  detected  by  a  patient  persistence.  Masses  are 
now  recognized  on  either  side  of  the  uterus  and  posterior  to  it,  and  occasionally 
straddling  it  beliind,  like  saddle-bags.  Each  mass  is  examined  in  turn  and  found 
tilling  the  posterior  half  or  two  thirds  of  the  pelvis  on  one  side,  more  or  less 
rounded,  with  a  slight  mobility  of  its  own  quite  distinct  from  that  either  of  the 
uterus  and  from  the  tixed  pelvic  walls,  and  it  is  usually  possible  to  rock  it  up 
and  down  for  at  least  a  centimeter. 

If  the  tumor  contains  pus,  a  sense  of  fluctuation  may  often  be  best  felt  by 
means  of  the  examining  tinger  in  the  rectum ;  but  if  there  is  but  little  pus  in 
a  thick  sac,  such  as  a  uterine  tube,  or  a  sac  surrounded  by  a  dense  cellulitis, 
fluctuation  is  entirely  absent. 

Sometimes  the  pelvic  abscess  is  so  large  as  to  form  a  visible  tumor  above  the 
symphysis,  and  a  bulging  red  area  in  the  groin  may  be  due  to  an  imminent 
rupture. 

Occasionally  an  accumulation  of  pus  on  one  side  presents  nothing  more  than 
the  physical  signs  of  a  small  ovarian  tumor  with  slight  lax  adhesions  allowing  a 
wide  range  of  mobility,  and  the  absence  of  all  the  characteristic  evidences  of 
inflammatory  reaction  may  confuse  the  diagnosis. 

In  a  few  instances,  however,  the  diagnosis  will  be  verified  in  a  surprising 
manner  by  a  free  discharge  of  pus  through  the  cervix,  which  can  be  kept  up  or 
increased  by  gentle  pressure  upon  the  mass,  emptying  the  abscess  more  or  less 
completely  through  the  tube,  the  uterus,  and  the  vagina.  Such  a  gush  of  pus 
frequently  takes  place  from  the  vagina  when  the  abscess  sac  is  grasped  and 
squeezed  in  the  open  abdomen  during  the  enucleation. 

By  the  rectal  examination  in  pelvic  abscess  or  densely  adherent  pyosalpinx 
the  narrow  part  of  the  bowel  above  the  ampulla  behind  the  cervix  often  feels 
like  an  auger  hole  in  a  board,  with  rounded  edges ;  above  this  the  tubes  and 
ovaries  are  felt  as  more  or  less  fluctuant,  bossed,  immovable  masses,  on  either 
side,  walling  in  the  rectum. 

The  temperature  is  significant  where  there  is  a  large  accumulation  of  pus, 
reaching  as  high  as  38-9°  to  40°  C.  (102°  F.  to  104°  F.)  or  more  ;  in  these  cases 
the  physical  signs  also  are  so  distinct  as  to  leave  no  doubt  as  to  the  diagnosis. 

The  treatment  of  tubal,  ovarian,  and  tubo-ovarian  abscesses  is  either  palliative 
and  expectant,  emptying  the  sac  by  massage,  vaginal  incision,  and  drainage,  or 
enucleation. 

In  general,  the  indications  establishing  the  special  lines  of  treatment  are  as 
follows :  An  expectant  line  of  action  must  be  pursued  in  all  cases  which  are 
rapidly  improving.  When  there  is  no  manifest  improvement,  or  the  change 
is  progressively  worse,  immediate  active  interference  is  the  only  safe  rule.  A 
sac  which  empties  spontaneously  through  the  uterus,  or  one  which  can  be  easily 
emptied  in  this  way  by  manipulation,  may  be  treated  by  massage  with  a  reason- 
able hope  of  ultimate  complete  recovery. 

Active  surgical  interference  is  the  rule  in  ninety-nine  out  of  every  one  hun- 
dred cases,  and  this  consists  either  in  letting  out  the  pus  through  the  vaginal 
vault,  or  in  opening  the  abdomen  and  removing  the  sac  with  or  without  the 


EMPTYIXG    THE    SAC    BY    MASSAGE.  221 

uterus.  Wherever  it  is  possible  to  reach  the  al)scess  through  the  vaginal  vault, 
with  or  without  the  aid  of  an  abdominal  incision,  the  patient  should  first  be 
given  the  advantage  of  a  trial  of  this  safer  method  of  treatment,  by  which  her 
pelvic  organs  are  spared.  Cases  which  continue  to  suffer  may  afterward  submit 
to  the  more  radical  procedure.  In  patients  who  are  extremely  ill,  the  rapid 
vaginal  operation  is  often  the  only  one  possible  under  the  circumstances. 

The  urgent  indication  is  always  to  evacuate  the  pus ;  when  that  is  effectively 
done,  the  adhesions  which  are  always  found  are  either  absorbed  or  may  give  rise 
to  no  further  discomforts.  If  the  patient  continues  to  suffer,  an  easier  and  a 
safer  operation  may  be  done  at  a  later  date  in  the  absence  of  pus. 

Expectant  treatment  is  limited  to  a  careful  observation  of  the  disease,  asso- 
ciated with  rest  and  regulation  of  the  bodily  functions,  and  is  only  applicable  in 
the  acute  stages  of  the  disease. 

In  rare  cases  the  pus  is  wholly  discharged  through  the  tubes  spontaneously, 
and  complete  recovery  takes  place.  Expectancy  is  necessary  in  the  acute  stages 
of  the  disease,  or  one  of  its  exacerbations,  on  account  of  the  increased  danger 
from  a  radical  operation  at  this  period.  While  waiting,  Nature  herself  may 
establish  an  avenue  of  discharge  at  a  point  favorable  for  complete  evacuation 
and  good  drainage. 

It  is  a  grave  error  to  hold  that  as  soon  as  the  diagnosis  of  pelvic  abscess  is 
established  the  next  step  should  be  an  immediate  radical  operation. 

During  the  acute  stages  of  the  formation  of  a  pelvic  abscess  the  patient  must 
be  kept  absolutely  at  rest,  the  bowels  freely  open,  and  ice  poultices  applied  to 
the  abdomen  ;  diaphoretics  should  be  given,  and  prolonged  hot  vaginal  douches 
used.  Some  morphine  is  necessary  to  allay  the  pain.  When,  under  such  a 
regime,  the  abscess  points  into  the  vagina  or  rectum  and  breaks  of  itself,  a  rapid 
recovery  may  follow.  I  have  several  times  ruptured  large  abscesses  in  this  way 
simply  with  the  finger  while  examining  the  case. 

Dilatation  of  the  cervix  and  curettage  have  been  vaunted  as  successful  in 
cases  of  well-defined  abscesses  to  promote  the  discharge  through  the  uterus,  but 
I  have  had  no  experience  to  enable  me  to  form  an  opinion. 

Evacuation,  next  to  expectancy,  is  the  simplest  plan  of  treatment,  and 
one  involving  few  risks  to  life  in  suitable  cases.  It  is  accomplished  by  one  of 
three  avenues — the  uterus,  the  vagina,  or  the  rectum.  Evacuation  through 
the  uterus  without  operation  may  be  systematically  carried  out  in 
cases  in  wliich  it  has  been  found  possible  in  a  bimanual  examination  to  squeeze 
pus  out  of  the  sac  through  the  uterus  and  when  the  symptoms  are  not  urgent. 

Evacuation  by  incision  is  the  proper  mode  of  treatment  in  cases 
pointing  into  the  vagina  or  rectum. 

Simple  evacuation  by  the  vagina  without  enucleation  is  also  indi- 
cated even  where  the  abdomen  has  been  opened,  and  the  removal 
of  the  adherent  tubes  and  ovaries  involve  unusual  risks  to  life. 

Emptying  the  Sac  by  Massage. — Emptving  the  sac  by  bimanual  comprossi(»n 
is  particularly  adapted  to  those  cases  in  which  the  abscess  forms  a  well-defined 
more  or  less  spherical  mass,  without  nuich  tenderness,  and  the  dense  hardness  of 


222  VAGINAL    DRAIXAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 

the  vaginal  vault  is  absent.  Success  by  this  form  of  treatment  may  be  antici- 
pated in  cases  presenting  a  history  of  discharges  of  pus  per  vaglnam.  Sur- 
rounded by  the  proper  safeguards,  this  plan  of  treatment  is  free  from  risk,  while 
^vithout  due  care  in  avoiding  rough  handling,  and  in  the  absence  of  a  projjer 
selection  of  cases,  there  is  imminent  danger  of  rupturing  the  sac  into  the  peri- 
toneal cavity,  and  so  exciting  a  fresh  and  even  fatal  attack  of  peritonitis. 

The  relations  of  the  pus  sac  should  lirst  be  thoroughly  investigated  under 
anesthesia  in  oi'der  to  know  just  whei*e  to  make  the  most  efficient  pressure. 
Before  each  massage  treatment  the  vagina  must  be  thoroughly  cleansed.  The 
legs  are  then  brought  well  up  and  the  chest  inclined  toward  the  abdomen,  pro- 
ducing the  most  marked  relaxation  of  the  abdominal  muscles  possible.  With 
one  hand  the  abdominal  walls  are  deeply  invaginated  into  the  pelvis.  When  the 
walls  are  thin  the  invagination  may  be  made  at  any  convenient  point,  but  in  thick 
or  rigid  walls  either  the  linea  alba  or  the  linea  semilunaris  form  the  most  yielding 
points.  The  vaginal  finger,  or  the  index  and  middle  fingers,  now  push  the  vagi- 
nal vault  behind  the  cervix,  high  up  and  into  the  back  part  of  the  pelvis  toward 
the  middle  of  the  sacral  hollow.  Both  hands  are  thus  brought  as  nearly  as  pos- 
sible together  behind  the  tumor  ;  then  with  a  little  relaxation  of  each  the  strain 
is  relieved,  the  tactile  sense  becomes  more  acute,  and  the  sac  is  palpated,  picked 
up  as  it  were,  by  the  hands,  while  a  gentle  pressure  is  begun  and  steadily  in- 
creased until  the  sac  is  squeezed  in  a  direction  toward  the  uterus.  The  pressure 
is  then  relaxed  for  a  moment,  and  the  sac  caught  again  and  squeezed  in  the  same 
direction  by  a  gentle  graduated  pressure  ;  this  process  is  repeated  at  intervals 
for  from  five  to  ten  minutes,  until  the  contents  are  milked  out  through  the 
uterus  into  the  vagina.  The  success  of  the  maneuver  will  often  be  indicated  by 
a  free  flow  of  pus  out  of  the  vagina  over  the  hand.  In  case  there  is  no  such 
free  discharge,  retraction  and  inspection  of  the  posterior  vaginal  wall  may  reveal 
the  presence  of  the  pus. 

Such  an  evacuation  should  be  made  once  or  twice  weekly,  and  the  patient 
kept  in  bed  afterward  for  several  hours  or  longer  if  there  is  any  pain  or  sign  of 
inflammation. 

In  order  to  test  the  value  of  this  treatment  as  a  curative  procedure  it  must 
be  kept  up  for  several  months,  mth  rest  at  the  menstrual  periods,  and  the  effects 
judged  by  the  general  condition  of  the  patient,  together  with  signs  of  local  im- 
provement, such  as  relief  from  pain,  and  the  most  important  evidence  of  all,  the 
fact  that  the  sac  fills  more  slowly,  or  fails  at  last  to  fill  at  all. 

Vaginal  Incision  and  Drainage.— The  first  cases  in  which  I  resorted  to  vagi- 
nal puncture  were  those  which  came  to  me  in  such  a  critical  condition  that  a 
radical  operation  was  impossible,  and  the  evacuation  of  the  pus  through  the 
vagina  was  done  simply  as  a  temporizing  measure  with  the  view  of  performing 
a  more  radical  operation  later,  when  the  patient  had  sufficiently  recovered  to 
permit  it  with  safety. 

The  records  of  the  first  cases  treated  in  this  way  showed  the  most  unexpected 
and  gratifying  results.  Of  fifteen  cases,  eight  were  permanently  relieved  with- 
out further  operation. 


VAGINAL   IXCISIOX    AXD    DRAINAGE.  223 

Three  of  these  patients  M'ere  young  women  (one  a^ed  twenty  years,  another 
nineteen  years,  and  a  third  seventeen  years)  in  whom  the  preservation  of  the 
function  of  the  ovaries  was  of  the  greatest  importance  to  future  health  and  hap- 
piness. Two  of  these  cases  were  examined  two  years  after  operation  ;  in  one  no 
evidence  of  the  former  disease  could  be  discovered  ;  in  the  other  the  appendages 
were  adherent  but  could  be  distinctly  outlined.  In  all  of  the  relieved  cases  the 
menstrual  flow  became  regular  and  was  unattended  by  pain. 

With  these  highly  satisfactory  results  as  a  basis,  I  extended  this  method  of 
treatment  to  a  much  wider  field. 

At  first  only  abscesses  in  which  fluctuation  could  be  detected  at  the  vault  of 
the  vagina  were  evacuated  by  puncture  ;  then  cases  of  dense  inflammatory  dis- 
ease, lateral  or  posterior  to  the  uterus  in  contact  with  the  vaginal  fornix,  or 
walled  off  from  the  general  peritoneal  cavity  by  adhesions,  and  finally  cases  of 
encysted  peritonitis  and  pyosalpinx,  were  frequently  treated  by  this  means  with 
good  results. 

Of  sixty-five  cases  treated  by  vaginal  puncture  up  to  Sept.,  1890,  there 
were  fifty-five  cases  of  pelvic  abscess  and  ten  of  clearly  defined  pyosalpinx  ;  in 
some  of  these  cases  there  was  a  pyosalpinx  on  one  side  and  a  hydrosalpinx  on  the 
other.  In  twelve  cases  there  was  encysted  peritonitis  and  dense  cellulitis.  The 
results  in  these  cases  M'ere  satisfactory  as  compared  with  the  higher  mortalitv 
and  slow  convalescence  in  similar  cases  treated  by  radical  operative  measures. 

Of  the  sixty -five  cases,  thirty-two  were  cured  and  two  died  ;  of  the  remain- 
der, some  were  greatly  relieved,  while  a  small  proportion  were  no  better.  In 
five  cases  operation  for  the  enucleation  of  the  diseased  structures  was  per- 
formed after  the  vaginal  puncture,  when  it  was  found  that  the  patient  was  only 
temporarily  relieved  by  this  procedure. 

The  following  are  the  steps  of  the  operation: 

1.  Cleansing  the  vagina  and  cervix. 

2.  Fixing  the  point  in  the  vaginal  vault  for  the  evacuation. 

3.  Pressing  the  vaginal  wall  well  up  against  the  point  with  the  index  finger, 
while  the  middle  finger  is  introduced  into  the  rectum  to  protect  it  from  injury. 

4.  Introduction  of  a  long  pair  of  sharp-pointed  scissors  on  the  index  finger 
up  to  the  point  of  puncture,  and  plunging  the  scissors  into  the  abscess  in  the 
direction  of  the  axis  of  the  pelvis. 

5.  Withdrawal  of  the  scissors  open,  to  enlarge  the  puncture,  followed  by  the 
introduction  and  withdrawal  of  a  larger  pair  of  blunt  scissors  or  uterine  dilators, 
making  an  opening  from  2^  to  3  centimeters  (1  to  1^  inch)  wide. 

0.  Introduction  of  the  finger,  and  careful  bimanual  palpation  of  the  sac  wall 
and  sui-rounding  structures,  with  the  finger  inside  the  sac,  with  a  view  of  discov- 
ering and  l)i"eal<ing  down  into  any  secondary  abscesses. 

7.  Curettage  of  the  lining  membrane  of  the  sac  wall. 

8.  Irrigation  of  the  cavity. 

9.  Packing  the  cavity  with  iodoform  gauze. 

10.  The  after  care,  consisting  in  keeping  the  cavity  open,  draining  freely 
and  clean. 


22i 


VAGINAL    DRAINAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 


The  proper  point  for  puncture  of  tlie  abscess  is  posterior  to  tlie  cervix  and 
in  the  median  line  or  just  to  the  right  or  left  of  it.  By  the  side  of  the  cervix 
there  is  danger  of  wounding  the  uterine  vessels  or  the  ureter.  The  artery  can 
usually  be  located  by  careful  palpation  against  the  resisting  wall  of  the  sac. 

The  handle  of  the  scissors  affords  a  good  grip,  by 
which  the  sharp  points  can  be  pushed  up  into  the  sac 
in  a  curved  direction  toward  the  second  sacral  vertebra, 
or  toward  the  sacral  promontory.  The  operator  must 
take  care  not  to  puncture  too  low  down, 
in  the  direction  of  the  lower  sacral  ver- 


/ 


Fig.   386.— Opening   a   Ketro-Uterine   Pelvic    Abscess   (Pes)   by   puncturing    the    Posterior   Fornix 
WITH  A  Pair  of  Sharp-Pointed  Scissors. 

The  points  of  the  scissors  are  conducted  in  the  direction  of  tlie  arrow.     It  is  usually  best  to  insert  the 
middle  finger  into  the  rectum  to  protect  it  from  injury. 


tebrse,  or  he  may  simply  transfix  the  bottom  of  the  cyst  and  penetrate  the 
rectum. 

If  the  cyst  is  a  little  above  the  vault  and  too  much  to  the  right  or  the  left, 
this  may  be  corrected  by  a  well-directed  pressure  made  by  the  hand  of  an  assist- 
ant on  the  lower  abdominal  wall. 

The  opening  should  not  be  made  too  much  to  one  side  for  fear  of  M^ounding 
a  ureter. 

The  position  of  the  uterine  artery  can  always  be  determined  by  palpation  at 
the  vaginal  vault ;  it  is  usually  felt  quite  prominent  and  pulsating  against  the 
anterior  wall  of  the  sac ;  knowing  its  exact  position  it  is  safe  to  enter  the  sac 
quite  close  to  it  if  necessary. 

As  soon  as  the  sac  is  entered  the  blades  are  easily  separated,  being  now  in  a 
free  space.  If  there  is  much  pus  present  it  commonly  begins  to  flow  at  once. 
By  withdrawing  the  scissors,  keeping  the  blades  open,  the  hole  is  torn  wider. 
Stout  dilators  with  parallel  blades  may  next  be  introduced,  or  a  large  pair  of 
blunt  scissors  may  be  used  as  a  dilator  and  withdrawn  open  as  before.  The 
orifice  can  thus  be  made  fully  as  broad  as  Douglas's  cul-de-sac — from  2|^  to  3 


VAGIXAL   IXCISIOX    AND    DRAINAGE.  225 

centimeters  (1  to  1^  inch) — and  tlie  pus  quickly  empties  itself  through  such  a 
wide  dependent  opening. 

The  index  finger  is  now  easily  introduced  through  this  hole,  and  the  size  and 
position  and  irregularities  of  the  sac  explored.  The  presence  of  other  collections 
of  pus  is  readily  determined  by  making  jDressure  with  the  external  hand  on  any 
doubtful  structures,  holding  them  steadily,  while  they  are  carefully  palpated  by 
the  finger  inside  the  sac. 

As  soon  as  a  well-defined  fluctuating  mass  is  felt,  if  there  is  no  doubt  of  its 
being  an  encysted  accumulation,  its  wall  may  be  broken  through  with  the  finger 
and  its  contents  evacuated  through  the  main  abscess  cavity.  Two  or  three  sepa- 
rate deposits  of  pus  may  be  released  in  this  way.  Great  care  must  be  taken  not 
to  overlook  any  such  collections,  because  complete  recovery  mil  only  follow  the 
evacuation  of  all  the  pus  in  the  pelvis. 

The  empty  sac  or  sacs  are  now  thoroughly  irrigated  with  sterile  water,  bring- 
ing away  all  the  pus  and  loose  tissue  debris^  and  a  loose  pack  of  washed-out 
iodoform  gauze  inserted  into  the  cavity  ;  finally  a  teaspoonful  or  more  of  the 
iodoform  and  boric-acid  powder  (1-T)  should  be  thrown  into  the  vault  of  the 
vagina  and  a  loose  vaginal  gauze  pack  inserted. 

In  the  case  of  a  large  abscess,  and  especially  when  it  is  situated  at  a  distance 
from  the  floor  of  the  peKds,  a  larger  and  freer  di'ainage  opening  is  secured  by 
exposing  the  vaginal  vault  with  specula  and  making  an  elliptical  incision  around 
and  behind  the  cervix,  so  as  to  excise  a  crescentic  piece  of  the  vaginal  vault  ex- 
tending up  into  the  peritoneum,  as  suggested  by  Dr.  G.  M.  Edebohls.  If  the 
edges  of  the  peritoneum  are  then  drawn  down  and  attached  to  the  vaginal  tissue, 


S^^^^ 


Fig.  387. — Stout  Curved  Saw-Toothed  Tkactiox  Forceps  for  removing 
THE  Gauze  Pack.     ^^  Size. 

The  jaws  sliown  full  size  below. 

a  pei-fectly  free  drain,  in  which  there  is  no  tendency  of  the  edges  to  drop  together, 
is  secured.  The  first  effect  of  the  operation  may  be  a  sharp  rise  in  the  tempera- 
ture, as  high  as  103°  to  105°  F.,  which  subsides  in  twenty-four  hours. 

After  establishing  free  drainage  great  relief  is  usually  felt  at  once.  If  the 
condition  of  the  patient  remains  good,  the  gauze  pack  in  the  sac  need  not  be 
disturbed  for  three  or  four  days,  or  longer,  when  she  is  brought  to  the  edge  of 


226  YAGIXAL    DRAINAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 

the  bed  or  table,  the  posterior  vaginal  wall  retracted,  all  the  gauze  removed  with 
a  suitable  pair  of  forceps,  and  the  cavity  well  cleansed  with  peroxide  of  hydro- 
gen or  boric-acid  solution  and  a  fresh  pack  applied.  This  cleansing  and  dressing 
must  be  renewed  daily,  always  using  speculum  and  dressing  forceps  instead  of 
fingers,  and  carefully  avoiding  any  contamination  of  the  sac  wall,  for  the  fact 
that  it  has  contained  pus  does  not  warrant  any  carelessness  as  to  infection  in 
the  after-treatment. 

Another  way  of  treating  the  drain  is  to  withdraw  the  gauze  slowly,  taking 
out  3  or  4  inches  every  day,  and  not  washing  out  the  sac  until  it  is  all  removed 
by  about  the  tenth  day. 

The  patient  may  rise  from  her  bed  and  go  about  the  room  in  eight  or  ten 
days  if  her  general  condition  warrants  it. 

Thei'e  is  little  danger  of  a  fi'ee  hemorrhage  if  the  operator  uses  some  care 
in  first  locating  the  uterine  artery  by  vaginal  touch.  In  the  sixty-five  cases  1 
have  referred  to,  hemorrhage,  beyond  that  expected  from  wounding  the  vas- 
cular vaginal  wall,  only  occurred  in  two  cases,  and  in  both  cases  it  was  easily 
controlled  by  a  firm  pack. 

Evacuation  of  the  pus  into  the  abdominal  cavity  must  be  guarded  against  as 
far  as  possible ;  but  since  we  have  learned  that  the  pus  from  these  cases  is  so 
frequently  sterile,  this  appears  as  a  much  less  serious  complication.  In  nine  of 
the  sixty -five  cases  punctured  ^e/"  vaginmn  the  free  peritoneal  cavity  was  opene:!, 
and  in  none  of  them  was  there  any  evidence  of  this  accident  in  the  after-symp- 
toms of  the  patient.  When,  however,  the  peritoneal  cavity  is  opened  the  pus 
must  be  most  thoroughly  removed  and  the  cavity  wiped  out  and  packed,  and 
irrigation  must  be  used  in  small  quantities  and  with  the  utmost  care. 

The  making  of  a  fecal  fistula  must  be  avoided  by  first  examining  the  rectum 
to  discover  its  exact  relation  to  the  abscess  sac,  and  by  keeping  one  finger  in  the 
rectum  during  the  operation  to  protect  it  from  injury.  Notwithstanding  these 
precautions,  a  small  opening  may  be  made,  but  it  will  usually  heal  quickly  if  the 
cavity  is  well  packed  with  gauze,  so  as  to  prevent  the  ingress  of  fecal  matter 
into  the  abscess  sac.  The  gauze  should  be  removed  daily  and  the  sac  well  iri'i- 
gated,  followed  by  the  firm  application  of  a  fresh  jDack,  with  the  patient  in  the 
knee-breast  posture. 

The  cases  most  likely  to  be  entirely  relieved  by  vaginal  drainage  are  those 
where  there  is  a  single  well-defined  collection  of  pus  which  can  be  evacuated 
completely.  When  the  cellular  tissue  is  more  or  less  honeycombed  with  mul- 
tiple abscesses  the  progress  of  the  case  will  be  slow,  and  may  require  repeated 
puncture  on  account  of  the  development  of  the  smaller  abscesses  after  the  cen- 
tral cavity  has  been  evacuated.  In  one  case  five  such  operations  were  required 
before  the  patient  was  finally  relieved. 

A  class  of  cases  not  likely  to  be  benefitted  are  those  in  which  there  is  dense 
inflammatory  tissue  without  fluctuation,  surrounding  the  rectum,  bladder,  and 
ureters.  Here  the  symptoms  do  not  come  from  the  collection  of  pus,  but  from 
the  effects  of  tlie  chronic  inflammatory  disease.  Of  the  sixty-five  cases  punc- 
tured j9€/'  vaginarii^  ten  were  of  this  class,  and  beyond  the  slight  relief  produced 


EVACUATION"    BY   THE    VAGINA    AIDED    BY    AN    ABDOMINAL   INCISION.       227 

bv  the  evacuation  of  a  small  quantity  of  pus,  the  patient  experienced  no  other 
benefits  from  the  operation. 

The  cavity  contracts  day  by  day  in  favorable  cases,  until  in  a  surprisinsjly 
short  time,  sometimes  not  more  than  two  weeks,  a  little  pit  at  the  vault  of  the 
vagina  is  all  that  remains.  This  is  finally  reduced  to  a  scar,  which  it  may  be 
hard  to  find  at  a  later  date. 

Yaginal  Incision  and  Drainage  in  Acute  Cases  of  Pel- 
vic Inflammation  .—A  novel  j)l.an,  proposed  by  Dr.  F.  Henrotin  {Trans. 
Amer.  Gyn.  Soc,  1895,  vol.  xx,  p.  223),  on  the  basis  of  his  experience  in 
twenty-seven  cases  of  acute  posterior  pelvic  inflammatory  affections,  deserves 
careful  attention.  In  the  absence  of  further  confirmatory  evidences  it  is  still 
impossible  to  form  a  satisfactoi'y  conclusion  and  to  give  this  procedure  its  due 
position  among  the  other  methods  of  treating  suppurating  affections.  The  pa- 
tient who  is  suffering  from  an  acute  recent  infection  in  its  earliest  stages  is 
treated  by  making  a  semicircular  incision  posterior  to  the  cervix  opening  the 
peritoneum,  after  which  the  finger  is  introduced  into  the  pelvis  and  used  in  all 
further  manipulations.  With  the  finger  the  adherent  inflammatory  mass  is 
reached,  punctured,  evacuated,  and  explored ;  in  the  majority  of  cases  an  ab- 
scess cavity  is  found.  Other  foci  of  inflammation  are  sought  out  and  opened, 
and  the  cavities  are  then  packed  with  gauze,  which  is  not  removed  for  three, 
four,  or  five  days,  unless  the  patient's  general  condition  indicates  a  retention  of 
the  secretions. 

Following  such  treatment,  the  pains  and  malaise  all  disappear,  and  the 
patients,  in  the  majority  of  instances,  make  a  rapid  recovery. 

The  author  of  this  plan  of  treatment  also  earnestly  advocates  a  thorough 
curettage  of  the  uterus  at  the  same  sitting. 

In  so  far  as  the  pain,  tenderness,  and  elevated  pulse  and  temperature  indi- 
cate the  presence  of  pus,  tl\e  general  rule  may  be  safely  followed  and  evacuation 
practiced.  Whether  it  will  prove  an  advantage  in  the  presuppurative  stages 
is  still  to  be  determined. 

Evacuation  through  the  Rectum. — Evacuation  through  the  rectum  is  only  ad- 
missable  when  there  is  such  a  marked  area  of  softening  that  spontaneous  rup- 
ture is  imminent,  and  then  the  opening  must  be  made  as  low  down  as  possible 
to  secure  constant  perfect  drainage. 

Under  no  circumstances  is  it  allowable  to  make  an  opening  high  up  above 
the  constriction  between  tlie  utero-sacral  folds.  If  l^ature  makes  an  opening  in 
such  a  position,  the  gases  and  fecal  matter  enter  the  sac  and  the  discharge  is 
kept  up  for  an  indefinite  period.  Where  the  pointing  is  high  up,  or  even 
where  an  opening  already  exists  at  this  point,  a  wide  counter-opening  should 
l»e  made  through  the  vaginal  vault  behind  the  cervix.  The  free  drainage  at 
this  point  prevents  any  accumulation  within  the  sac  and  allows  the  higher  orifice 
to  close. 

Evacuation  by  the  Vagina  aided  hy  an  Abdominal  Incision. — Evacuation  of 
pelvic  abscesses  by  the  vagina,  controlled  l)y  the  hand  introduced  within  the 
abdominal  cavity,  is  called  for  when  the  abscess  is  not  so  clearly-  defined  as  to 


228 


VAGINAL    DRAINAGE   AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 


admit  of  operation  by  the  vagina  alone,  or  when  upon  opening  the  abdomen  the 
adhesions  are  found  so  dense  and  widespread  that  an  enucleation  of  the  whole 
mass  would  be  attended  with  imminent  risk  to  life,  or  again  when  the  ex- 
tremely weakened  condition  of  the  patient  renders  drainage  safer  than  enuclea- 
tion. In  the  sixty-five  cases  of  pelvic  inflammatory  disease  treated  by  vaginal 
puncture  an  exjiloratory  abdominal  section  was  done  in  twenty-one. 

It  is  also  a  better  plan  of  treatment  in  atypical  accumulations  of  pus,  such  as 
deposits  around  the  ligatures  and  the  stump  of  a  previous  operation,  or  where 
pus  pockets  are  walled  in  by  intestines,  or  in  all  cases  where  the  anatomical  rela- 
tions of  the  sejjtic  focus  forbid  enucleation.  Under  such  conditions  if  the  in- 
fected tissues  lie  in  contact  with  the  pelvic  floor,  a  wide  opening  may  be  made 
through  the  vaginal  vault,  giving  abundant  drainage  below,  and  at  the  same 
time  avoiding  injury  to  the  peritoneum  by  controlling  the  operation  through 
the  hand  introduced  within  the  abdomen. 

Similarly,  if  an  abscess  can  not  be  enucleated  after  carefully  studying  its  rela- 
tions through  the  abdominal  incision,  the  peritoneal  cavity  is  guarded  with  one 
hand,  while  the  other  carries  the  sharp-pointed  scissors  up  to  the  vaginal  vault, 
which  is  perforated  behind  the  cervix  in  the  direction  indicated  by  the  hand 
within  the  abdomen.  The  opening  in  the  vaginal  vault  is  then  enlarged,  the 
finger  thrust  in,  and  the  whole  abscess  area  rapidly  broken  open  into  one  sac, 

under  the   guidance  of  the 
hand  within. 

On  account  of  the  con- 
tamination of  the  hand  hold- 
ing the  scissors,  the  operator 
now  leaves  the  patient  to  the 
assistant,  who  closes  the  ab- 
dominal incision  and  packs 
the  cavity  with  washed-out 
iodoform  gauze,  with  the 
ends  brought  out  into  the 
vagina. 

The  further  treatment  of 
the  abscess  cavity  is  to  leave 
the  gauze  in  for  several  days, 
when  it  is  removed  and  the 
cavity    washed    out    daily ; 
enough   gauze   is   put    back 
after  each  washing  to  keep 
the  opening  into  the  vagina 
from  closing  before  the  cav- 
ity above  has  contracted. 
One  of  the  worst  cases  I  have  ever  seen  was  successfully  treated  in  this  way. 
The  patient  was  in  a  low  typhoid  unconscious  condition,  with  a  parched  brown 
tongue  and  pulse  at  1-iO.     On  opening  the  abdomen  the  pelvis  was  found  choked 


Fig.  SbH. — Abscess  of  both  Fallopian  Tubes  treated  through 
AN  Abdominal  Incision  by  rp;leasing,  opening,  and  wash- 
ing OUT  the  Tubes,  and  then  dropping  them  with  the  Ova- 
ries ONTO  A  Gauze  Drain  leading  through  the  Posterior 
Fornix  into  the  Vagina.     March  4,  18',)G. 


EVACUATIOX   BY   THE    VAGIXA    AIDED    BY    AX    ABDOMIXAL    IXCISIOX.        229- 

by  densely  adherent  masses  which  could  not  be  differentiated.  It  was  evident 
that  life  could  not  be  saved  if  the  operation  was  prolonged,  so  I  made  a  free 
vaginal  opening,  and  evacuated  about  350  cubic  centimeters  of  thick  fetid  pus. 
She  slowlv  recovered  after  several  weeks  of  delirium,  and  is  now,  three  years 
after,  in  good  health,  without  any  evidence  of  jielvic  disease. 


Fig.  389. — Showing  the  Gauze  Drain  filling  the  Cul-de-sac  behind  the  Uterus  and  leading 

DOWN  into  the  V.\gina. 


TThen  a  pyosalpinx  is  situated  high  up  in  the  pelvis  and  is  not  in  contact 
with  the  vaginal  vault  it  may  be  necessary  to  free  the  adhesions  and  push  the 
pus  sac  or  sacs  down  into  Douglases  cid-de-mc^  where  they  may  be  more  easily 
and  safely  reached  by  the  vaginal  puncture.  The  following  ease  well  illustrates 
this  plan  of  treatment : 

A.  C,  4180,  March  4,  1896.  Chief  complaint,  severe  lower  abdominal  pains, 
with  recurrent  attacks  of  fever  and  chills. 

She  had  been  married  sixteen  years  and  had  one  child,  born  eleven  years  ago 
After  a  difficult  natural  labor.  Complete  rupture  of  the  recto-vaginal  septum 
occurred,  and  she  was  confined  to  bed  for  two  months  with  puerperal  fever ;  she 
has  had  four  operations  since  in  the  endeavor  to  cure  the  tear,  and  each  time 


230  VAGINAL    DRAINAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 

infection  caused  a  failure.  In  1889  she  was  operated  upon  for  the  fifth  time 
successfully. 

In  Jan.,  1896,  after  exposure  to  cold  she  began  to  have  an  offensive  hemor- 
rhagic discharge,  accompanied  by  chills  and  fever,  and  her  abdomen  became 
swollen  and  tender,  bowels  constipated,  defecation  very  painful.  At  the  begin- 
nins:  of  the  attack  her  fever  was  high  and  she  vomited  much  bilious  matter. 

This  attack  continued  throughout  February,  becommg  less  and  less  severe 
until  the  present  time.  The  point  of  greatest  tenderness  is  now  in  the  right 
iliac  region,  extending  across  the  abdomen.  There  is  no  tympanites,  but  the 
abdomen  is  tender.     Micturition  is  painful,  and  the  urine  is  loaded  with  mucus. 

Her  general  condition  is  one  of  extreme  debility,  her  tongue  is  coated,  appe- 
tite poor,  and  she  is  anemic. 

Examination. — Yaginal  outlet  relaxed,  uterus  anteflexed,  cervix  bilat- 
erally lacerated.  On  both  sides  of  the  uterus  adherent  fluctuating  fusiform 
masses. 

Diagnosis. — Right  ovarian  abscess  and  pyosalpinx  ;  left  pyosalpinx  and 
cystic  ovary  ;  general  pelvi-peritonitis  with  fresh  adhesions  to  rectum,  pelvic 
walls,  broad  ligaments,  uterus,  and  pelvic  floor. 

Complications . — Fresh  plastic  lymph  gluing  all  organs  togetlier  and 
causing  free  oozing  on  separating  adliesions. 

Operation . — Abdominal  incision  for  the  purpose  of  accurately  locating 
the  masses  which  were  situated  high  up  in  the  pelvis,  and  not  in  contact  with 
the  vaginal  fornix,  followed  by  an  opening  in  the  posterior  wall  of  the  vagina, 
evacuation  of  pus,  and  drainage. 

The  pelvis  was  choked  with  the  uterus,  pyosalpinx,  cystic  ovary,  and  ovarian 
abscess,  adhering  to  all  contiguous  structures,  and  the  interspaces  were  filled 
with  plastic  lymph.  The  adherent  organs  were  detached  with  difficulty,  but 
without  tearing  the  rectum.  An  abscess  of  the  ovary,  4  centimeters  (1^  inch)  in 
diameter,  ruptured  during  the  separation  of  the  adhesions,  discharging  pus  onto 
the  surrounding  gauze  ;  the  distended  tube  was  separated  from  its  adhesions  to 
the  ovary,  and  its  fimbriated  end  was  split  open  and  necrotic  material  and  some 
pus  squeezed  out. 

The  left  tube  was  brought  up  and  treated  in  the  same  way,  but  there  was  no 
pus  in  the  left  ovary.  After  freeing  the  tube  from  its  adhesions  the  closed 
extremity  was  split  open  and  a  small  amount  of  pus  squeezed  out.  The  vagi- 
nal vault  posterior  to  the  cervix  was  then  opened  and  a  gauze  drain  was  pulled 
through  from  above  downward.  The  tubes  and  ovaries  embraced  the  uterus  be- 
hind, touching  each  other,  and  filling  in  the  posterior  pelvis,  with  the  fimbriated 
extremities  lying  in  Douglas's  cul-de-sac  resting  on  the  gauze  drain. 

The  patient  recovered  slowly  but  steadily.  The  vaginal  drain  was  removed 
with  little  difficulty,  moistened  with  a  slightly  offensive  yellowish  discharge; 
after  the  removal  there  M^as  no  discharge.  The  post-operative  temperature  at 
no  time  rose  above  100°  F.  (37-8°  C). 

She  left  the  hospital  five  weeks  after  the  operation,  and  was  seen  several 
months  later  perfectly  well  and  hard  at  work  as  a  canvassing  agent. 


ENUCLEATION    OF    PYOSALPINX    AND    OVARIAN    ABSCESSES.  231 

Enucleation  of  Pyosalpinx  and  Ovarian  Abscesses  (Salpingo-oophorectomy). — 
In  enucleating  a  pyosaJpinx  or  an  ovarian  abscess  the  first  step  after  opening  the 
abdomen  is  to  make  a  careful  inspection  of  the  relations  of  all  the  pelvic  viscera. 

If  omental  adhesions  interfere  with  the  examination  they  must  be  separated 
by  catching  the  omentum  close  to  the  adhesion  and  tearing  them  loose  from 
their  adhering  surface  with  gentle  force,  or  by  tying  them  off. 

If  the  fundus  uteri  is  found  at  or  near  its  normal  position,  the  fingers  then 
readily  glide  over  the  cornua  from  one  side  to  the  other,  and  palpate  the  more 
or  less  hard  nodular  masses  filling  the  pelvis  on  both  sides  posterior  to  the  broad 
ligaments. 

It  is  by  no  means  rare  for  the  operator  not  to  be  able  to  discover  the  uterus 
at  all,  because  it  is  so  covered  over  with  its  diseased  lateral  structures  and  inflam- 
matory products,  even  uniting  the  bladder  to  the  rectum. 

As  soon  as  the  diseased  tubes  or  ovaries  are  located,  the  relations  of  each  to 
all  the  structures  with  which  it  lies  in  contact  must  be  studied  separately  by 
sight  and  by  touch,  pushing  a  little  here  and  there  to  determine  the  amount  of 
mobility,  and  noting  with  care  any  dense,  hard,  unyielding  attachments,  and 
especially  all  bowel  adhesions. 

As  a  result  of  this  thorough  preliminary  inspection  the  operator  concludes 
whether  he  will  or  will  not  be  able  to  make  a  satisfactory  enucleation.  It  is  im- 
possible here  to  lay  down  such  precise  rules  as  will  serve  to  guide  the  inexpe- 
rienced surgeon  in  all  cases,  but  it  is  undoubtedly  true  that  operations  of  this 
character  which  appear  at  first  sight,  and  to  a  beginner,  impossible,  are  readily 
performed  by  a  more  experienced  gynecologist.  If  the  structures  can  be  out- 
lined, and  are  found  to  be  slightly  movable,  an  enucleation  will  always  be  possi- 
sible ;  if,  on  the  other  hand,  they  are  densely  wedged  in  the  posterior  pelvis  and 
adhere  to  the  pelvic  Walls  as  if  frozen  there,  an  enucleation  ought  never  to  be 
attempted ;  the  abscesses  must  then  be  evacuated  by  the  vaginal  route,  aided  by 
one  hand  in  the  open  abdomen. 

If  the  masses  are  to  be  removed,  evidences  of  fluctuation  are  sought  for  and 
the  aspirator  inserted,  so  as  to  draw  off  the  pus  into  a  sterile  bottle ;  cultures 
should  then  be  taken,  and  cover-glass  preparations  made  for  immediate  micro- 
scopic examination.  The  puncture  hole  should  be  closed  with  a  single  mattress 
suture.  Any  pus  that  escapes  accidentally  should  be  taken  up  at  once,  and 
pieces  of  gauze  and  sponges  should  be  stuffed  down  into  the  pelvis  and  on  all 
sides  above  the  pelvic  brim,  so  as  to  protect  the  adjacent  parts  from  contamina- 
tion. The  sides  of  the  abdominal  incision  should  also  be  protected  throughout 
the  operation  by  several  layers  of  gauze. 

AVhen  a  large  abscess  ruptures  during  an  operation,  with  the  pelvis  elevated, 
the  patient  must  at  once  be  let  down  to  a  level  to  prevent  the  extensive  contami- 
nation of  the  intestines. 

All  intestinal  adhesions  should  be  separated  under  the 
eye;  velamentous  adhesions  can  be  pinched  off  close  to  the  sac,  but  flat,  dense 
cicatricial  adhesions  must  be  dissected  off  with  the  knife  or  scissors,  even  leaving 
a  part  of  the  outer  wall  of  the  abscess  adhering  to  the  intestine.     If  any  of  the 


232  VAGINAL    DRAINAGE    AND    ENUCLEATION    FOR    PYOSALPINX,    ETC. 

pyogenic  lining  membrane  of  the  cyst  is  left  beliind,  this  can  be  disinfected 
either  by  touching  it  with  pure  carbolic  acid  or  by  destroying  the  surface  with 
the  cautery,  or  by  scraping  it  o&  with  a  scalpel. 

The  successful  enucleation  of  the  diseased  tube  and  ovary  depends  upon  two 
factors  :  A  good  tactile  sense,  which  constantly  differentiates  the  structures 
under  the  fingers  and  readily  recognizes  the  lines  of  cleavage  between  the  dis- 
eased organs  and  the  adherent  peritoneal  surfaces,  and  a  knowledge  of  the  usual 
topographical  relations  of  ovarian  and  tubal  abscesses. 

The  natural  points  of  cleavage  are  opposite  to  the  normal  ana- 
tomical attachments  of  the  tube,  along  the  dorsal  and  dorso-lateral  pelvic  walls, 
and  between  the  two  abscess  sacs  where  they  touch  behind  the  uterus. 

"When  the  cysts  are  completely  covered  with  dense  organized  tissue  an  en- 
trance must  sometimes  be  effected  by  dissection  with  the  knife,  after  which  the 
further  separation  is  not  so  difficult. 

By  palpating  around  the  dorsal  wall  of  the  pelvis  a  weak  spot  will  usually 
be  found,  and  then  by  working  one  or  two  fingers  down  here  the  split  is  widened 
and  the  cyst  may  be  peeled  off  from  side  to  side,  while  the  fingers  continue  to 
advance  on  down  toward  the  pelvic  floor,  at  first  behind  and  then  under  the 
mass. 

As  the  fingers  advance,  the  separation  from  side  to  side  is  kept  up  until  the 
mass,  freed  from  the  dorsal  pelvic  wall  and  the  pelvic  floor  is  grasped  by  the 
fingers  and  rolled  forward  and  upward  toward  the  incision,  using  the  upper 
part  of  the  broad  ligament  as  an  axis.  This  completes  the  separation  of  adhe- 
sions to  the  broad  ligament.  Adhesions  at  the  outer  pole  of  the  mass  to  the 
rectum  or  pelvic  wall,  and  at  the  inner  pole  to  the  uterus,  are  now  looked  for 
and  separated  under  inspection. 

The  whole  mass,  sometimes  as  large  as  the  fist,  but  made  up  only  of  tube 
and  ovary,  is  now  brought  out  of  the  incision,  still  retaining  its  normal  attach- 
ments to  the  ovarian  liiliim  and  ligament,  to  the  mesosalpinx  and  cornu 
uteri,  and  to  the  infundibulo-pelvic  ligament.  As  soon  as  these  structures 
are  brought  outside,  a  sponge  or  loose  piece  of  gauze  is  packed  down  into  the 
incision  behind  the  broad  ligament  to  protect  and  hold  back  the  intestines. 

The  mass  to  be  amputated  should  be  enclosed  in  a  gauze 
bag  several  folds  thick  the  moment  it  is  liberated;  this 
affords  a  good  grasp  and  protects  the  hand  and  the  surrounding  tissues  from  the 
contamination  of  any  escaping  pus.  The  method  of  ligation  and  excision  of  the 
tube  is  the  same  as  that  described  in  Chapter  XXVI,  p.  207. 

It  will  usually  be  found  that  the  ovary  is  not  diseased  itself,  but  is  merely 
involved  in  adhesions  due  to  the  accident  of  its  position  in  the  pelvis  in  prox- 
imity to  the  tube ;  under  these  circumstances  the  ovaries  should  be  left  in 
women  under  forty. 

When  the  disease  is  bilateral  the  opposite  side  is  similarly  treated. 

If  persistent  oozing  is  noticed  aftef  the  enucleation,  its  source  must  be 
sought  out  and  inspected  by  packing  away  the  intestines  with  fingers  and 
sponges.      A  slight,   constant  oozinr;  from   a  flat   surface  on  the  pelvic  floor 


EXUCLEATIOX    OF    PYOSALPIXX    AXD    OVARIAX    ABSCESSES.  233 

may  be  controlled  by  a  little  dried  persulphate  of  iron  applied  on  the  finger  tip, 
or  the  cautery  may  be  used  ;  bleeding  from  a  large  vessel  must  be  controlled 
by  ligatures  introduced  by  the  needle  and  carrier.  Hemorrhage  from  a  uterine 
adhesion,  or  from  the  side  of  the  uterus  where  it  joins  the  broad  ligament,  or 
from  the  ovarian  hilum,  nmst  be  controlled  by  the  free  use  of  ligatures  through 
the  uterine  tissue  and  through  the  broad  ligament. 

Persistent  active  oozing  will  occasionally  be  found  to  proceed  from  the  outer 
end  of  a  tube  which  has  been  torn  in  two  in  the  enucleation,  or  from  an  ad- 
herent piece  of  the  abscess  wall  left  behind.  These  may  be  easily  removed  with 
forceps  or  fingers,  and  the  bleeding  ^vill  cease.  Irrigation  is  indicated  where 
pus  has  escaped  during  the  operation  and  there  is  some  probability  that  the  in- 
testines have  been  more  or  less  contaminated.  If  the  cyst  is  aspirated  before 
enucleation  the  liability  to  contamination  is  greatly  reduced. 

The  peMs  should  now  be  cleansed  with  sponges,  and  tlien  the  sides  of  the 
incision  may  be  pulled  up  and  as  much  hot  salt  solution  poured  in  as  the  pelvis 
will  hold. 

The  hot  salt  solution  should  be  stirred  about  in  the  pelvis  with  the  hand 
or  with  a  sponge  on  a  holder,  and  the  water  then  sponged  out  and  more  poured 
in  ;  this  may  be  repeated  several  times,  until  the  surgeon  is  satisfied  that  the  pus 
has  been  well  diluted  and  removed. 

After  drying  out  the  abdomen  the  last  step  is  a  minute,  deliberate  inspection 
of  the  whole  field  of  the  operation  to  see  if  the  ligatures  are  all  in  place  and 
holding  well,  if  all  bleeding  is  checked,  and  if  any  intestinal  adhesions  have 
been  overlooked.  It  is  most  important  to  examine  minutely  the  rectum  from 
the  pelvic  brim  to  the  pelvic  floor  in  search  of  a  fistulous  opening  or  a  rent  in 
the  outer  coats  of  the  bowel. 

The  employment  of  a  drain  in  these  cases  is  of  no  value  and  may  give  rise 
to  serious  harm,  and  it  is  therefore  much  better  to  close  the  abdomen  without 
drainage  unless  a  septic  focus  or  a  much  injured  bowel  has  been  left  behind, 
when  a  vaginal  drain  should  be  inserted  behind  the  cervix. 

In  order  to  prevent  the  accumulation  of  fluids  in  the  raw  areas  left  after  dif- 
ficult enucleation  of  diseased  appendages,  500  cubic  centimeters  of  salt  solution 
should  be  left  in  the  abdominal  cavity  after  operation,  and  when  the  patient  is 
returned  to  her  room  the  bed  should  be  elevated  about  twenty  degrees  in  order 
to  facilitate  the  rapid  absorption  by  the  lymph  channels  of  the  fluids  and  accu- 
mulating serum.  The  addition  of  the  salt  solution  dihites  any  infectious  matter 
present,  and  not  only  hastens  its  absorption,  but  also  lessens  the  irritant  effects 
of  the  toxic  products  of  the  bacteria. 

When  the  abdomen  is  opened  for  a  pelvic  abscess  and  a  widespread  or  a 
general  purulent  peritonitis  is  found,  the  course  pursued  by  the  oi)erator  will 
depend  upon  the  condition  of  the  patient.  If  she  is  so  weak  that  she  can  pre- 
sumably only  stand  an  operation  of  the  shortest  duration,  the  best  plan  will  be 
to  irrigate  rapidly,  cleaning  out  all  the  accessible  pus  with  a  sponge,-  paying  spe- 
cial attention  to  the  pelvic  cavity  and  the  renal  fossae.  If  the  time  is  too  short 
to  permit  the  enucleation  of  the  pelvic  abscess,  this  should  at  least  be  squeezed 


234 


VAGINAL    DRAINAGE    AND    ENUCLEATION   FOR    PYOSALPINX,    ETC. 


empty  and  a  free  drainage  opening  made  into  the  vagina  back  of  the  cervix  and 
the  abdomen  closed. 

When,  however,  tlie  patient's  condition  will  permit  it,  the  entire  abdominal 
cavity  shonld  be  washed  out  and  the  separate  coils  of  intestines  drawn  np  in  an 
orderly  manner  and  wiped  off,  and  the  mesentery  cleansed,  so  that,  as  far  as  pos- 
sible, every  trace  of  pus  is  removed.  It  must  be  remembered  that  only  one  third 
of  the  intestinal  canal  lies  in  contact  with  the  abdominal  wall  and  that  there  is 


Fig.  390. — Ovarian  Abscess. 


(A)  Densely  adherent  to  the  rectum,  with  retroflexed  adherent  uterus  ( ^7") ;  general  pelvic  peritonitis  of 
the  severest  form,  involving  both  tubes  and  ovaries.  Omental  adhesions  ( (?)  48  centimeters  around  the 
border.  Pus  in  abscess  sterile.  Enucleation  of  uterus,  tubes,  and  ovaries.  Kecovery.  Gyn.  No.  2825. 
M.  v.,  June  13,  1894. 


an  enormous  extent  of  peritoneal  surface  distributed  over  the  mesentery,  so  that 
after  simply  washing  off  what  is  exposed  to  view  through  an  abdominal  incision, 
much  more  is  left  behind  which  still  more  urgently  demands  attention.  Liberal 
gauze  drains  should  then  be  inserted  in  the  median  line  leading  down  into  the 
pelvis  and  out  onto  the  coils  of  intestines.  The  flanks  should  also  be  opened 
and  gauze  drains  put  in  there  to  catch  any  fluids  gravitating  in  that  direction. 
In  this  way  several  yards  of  gauze  may  be  employed  and  gradually  removed  in 


ENUCLEATION    OF    PYOSALPINX    AND    OVARIAN   ABSCESSES.  235 

a  few  days.     When  the  uterus  is  extensively  diseased  either  by  a  chronic  endo- 
metritis or  contains  numerous  myomata,  or  is  cancerous  at  the  same  time,  as 


i£. 


Fig.  391. — Double  Ptosalpinx  with  Carcinoma  of  the  Cervix. 

Showing  a  case  of  not  uncommon  occurrence  in  which  it  is  necessary  to  enucleate  both  tubes  and  the 
entire  uterus.     The  pus  in  both  tubes  was  sterile.     No.  308.    %  natural  size. 

shown  in  Fig.  391  and  Plate  XIY,  the  enucleation  should  then  include  the  body 
or  the  entire  uterus  with  the  infected  tubes,  and  the  operation  should  be  per- 
formed as  described  in  Chapter  XXYIII. 


CHAPTER   XXYIII. 

HYSTERECTOMY,  "WITH   EXTIRPATION   OF   OVARIES  AND   TUBES- 
ABDOMINAL   HYSTERO-SALPINGO-OOPHORECTOMY. 

1.  Indications  for  operation  and  analysis  of  one  hundred  cases. 

2.  Reasons  for  removing  the  uterus. 

3.  Operation. 

4.  Complications  in  one  hundi'ed  cases. 

5.  Mortality. 

Indications  for  Operation. — The  removal  of  the  uterus  with  diseased  ovaries 
and  tubes  by  the  abdominal  route  is  indicated — 

1.  Where  previous  efforts  at  conservatism  have  failed. 

2.  Where  the  uterus  is  involved  in  inflammatory  products,  buried  beneath 
masses  of  adhesions,  or  beneath  bladder  and  rectum  adherent  together  over  the 
top  of  the  uterus. 

3.  Where,  in  addition  to  the  extensive  lateral  disease,  the  uterus  is  subinvo- 
luted  or  there  is  a  chronic  metritis. 

4.  Where  the  incurable  disease  of  the  tubes  and  ovaries  is  complicated  by  a 
uterus  containing  myomata. 

5.  In  general,  where  the  enucleation  en  masse  is  technically  much  easier  and 
therefore  safer  than  the  removal  of  the  lateral  structures  alone. 

6.  In  cancer  of  the  body  of  the  uterus. 

7.  When  both  ovaries  are  the  seat  of  papillary,  dermoid,  or  multilocular  cysts. 
The  diseases  of  the  ovaries  and  tubes  most  likely  to  be  found  with  such  a 

uterus  are  double  pyosalpinx,  or  pyosalpinx  of  one  side  and  hydrosalpinx  of  the 
other,  or  double  hydrosalpinx,  or  general  posterior  jDelvic  peritonitis  binding 
down  the  uterus,  ovaries,  and  tubes. 

I  have  found  it  necessary  to  remove  the  uterus,  tubes,  and  ovaries  in  one 
hundred  cases  for  the  following  reasons :  For  j)yosalpinx  in  38 ;  for  ovarian 
abscess,  2 ;  for  pelvic  abscess,  involving  both  tubes  and  ovaries,  18 ;  for  salpin- 
gitis and  perioophoritis,  22 ;  for  hydrosalpinx  and  pelvic  peritonitis,  15  (once 
with  dermoid  cyst) ;  endometritis,  pain,  and  hemorrhages  not  relieved  by  a  pre- 
vious salpingo-oophorectomy,  2 ;  tuberculosis  of  ovaries  and  tubes,  3. 

Out  of  sixty-five  cases  of  pelvic  abscess  treated  by  a  free  vaginal  incision  and 
drainage  I  found  it  necessary  at  a  later  date  to  resort  to  the  radical  plan  of  ex- 
tirpating uterus,  tubes,  and  ovaries  in  five  cases. 

This  most  radical  procedure  must  be  carefully  guarded 
by    operating    only    upon     suitable     and    stringent    indica- 

236 


INDICATIONS    FOE    OPERATION. 


237 


t  i  o  n  s ,     In  young  women,  when  the  ovaries  are  not  diseased,  they  must  be  left 
in  the  pelvis,  confining  the  enucleation  to  the  tubes  and  the  uterus. 

The  removal  of  the  uterus  with  the  tubes  and  ovaries  is  to  be  recommended 
because  without  the  ovaries  it  is  a  useless  organ,  which  may  of  itself,  at  a  later 
date,  become  the  source  of  such  serious  disturbances  as  to  require  its  removal. 
In  almost  all  pelvic  inflammatory  cases  the  uterus  is  traceable  as  the  avenue  of 


Fig.  392. — Extirpation  of  Myomatous  Uterus,  Ovaries,  and  Tubes  with  a  Left  Ovarian  Cystoma. 

The  uterus  is  filled  with  niyoinata,  and  the  left  ovary  is  converted  into  a  large  ovarian  cyst.     C,  cervix; 
F,  fundus.     The  dotted  line  is  the  median  line  of  the  body.     No.  443.    ^  natural  size. 


infection,  and  the  retention  of  an  infected  subinvoluted  uterus  often  insures  the 
persistence  of  a  leucorrheal  discharge,  protracted  hemorrhages,  and  a  sense  of 
weight  and  pelvic  discomfort,  which  seriously  mar  the  result  of  the  operation. 

In  addition  to  these  reasons,  many  of  the  uteri  operated  upon  for  these  con- 
ditions are  lifted  out  of  beds  of  adhesions,  and  when  freed  present,  on  the  ab- 
dominal side,  an  extensive  raw  surface  which  is  liable  to  contract  adhesions  with 
contiguous  intestines.  In  a  large  percentage  of  cases,  too,  not  only  the  tubes 
and  the  ovaries  are  infected,  but  the  uterine  coruua  as  well,  necessitating  at  least 
a  partial  amputation  if  the  uterus  is  left  behind. 

The  backward  displacement  of  the  uterus  onto  the  pelvic  floor  when  robbed 
of  its  adnexa  may  also  cause  much  distress,  and  obstruction  of  the  rectum. 

If  the  uterus  is  not  taken  out,  the  pedicles  at  the  top  of  the  broad  ligaments 
are  exposed  to  the  right  and  to  the  left  of  it,  which  is  avoided  by  amputating 
the  uterus  in  the  cervical  portion  and  covering  in  the  whole  wound  with  peri- 
toneum, so  as  to  leave  no  exposed  raw  surfaces  to  contract  adhesions.  Para- 
doxical as  it  may  seem,  it  is  easier  to  take  out  the  uterus  with  its  adnexa  than  to 
extirpate  densely  adherent  tubes  and  ovaries  alone.  The  complete  extirpation 
aifords  a  better  view  of  the  entire  pelvis,  the  ligation  of  the  uterine  artery  gives  a 
better  control  of  hemorrhage,  fewer  raw  areas  are  left,  the  operation  may  be 
actually  of  shorter  duration,  and  better  drainage  is  secured  if  it  is  called  for. 


238  HYSTERECTOMY,    WITH    EXTIRPATION    OF    OVARIES   AND   TUBES. 

For  these  important  reasons  liystero-salpingo-oopliorectomy  is  to  be  preferred 
to  double  salpingo-oopliorectomy. 

1  would  only  except  those  cases  in  which  the  patient  emphatically  expresses 
a  desire  not  to  have  the  uterus  removed,  and  in  which  there  is  a  small  mobile 
uterine  body  not  involved  in  the  disease. 

There  exists  among  surgeons  a  wide  divergence  of  views  regarding  the  rela- 
tive advantages  of  the  abdominal  and  vaginal  routes  in  the  extirpation  of  the 
uterus  and  its  appendages.  I  have  always  held  that  the  abdomen  was  the  best 
avenue  for  the  following  reasons  :  First  and  foremost,  the  operator,  upon  open- 
ing the  abdomen,  has  a  chance  to  inspect  the  condition  of  the  structures 
lateral  to  the  uterus  and  to  decide  whether  or  not  a  conservative  course  may  be 
safely  followed;  the  abdominal  route  allows  the  entire  operation  to  be  done 
under  the  constant  supervision  and  criticism  of  the  clearest  inspection  of  the 
entire  field  ;  complications  such  as  intestinal  adhesions,  and  particularly  adhesion 
or  abscess  about  the  vermiform  appendix  (attached  in  twenty-seven  out  of  one 
hundred  of  my  cases),  can  be  seen  and  safely  dealt  with ;  ligatures  are  applied 
with  certainty,  and  hemorrhage  is  seen  and  easily  controlled ;  the  ureter  and 
bladder  are  not  so  liable  to  injury  ;  and  finally  the  quick,  clean  recovery  follow- 
ing an  abdominal  operation  is  far  preferable  to  the  sloughing  and  protracted 
suppuration  and  slow  healing  so  common  after  removing  the  uterus  through  the 
vagina  and  using  clamps  on  the  broad  ligaments. 

Operation. — The  incision  is  made  in  the  linea  alba  from  10  to  15  centimeters 
(4  to  6  inches)  long — a  shorter  cut  if  the  walls  are  thin,  a  longer  one  if  they  are 
thick.  If  the  omentum  is  adherent  it  is  first  released,  bleeding  points  tied,  and 
any  free  fiuid  carefully  removed  by  means  of  sponges. 

If  the  intestines  do  not  fall  out  of  the  way  into  the  upper  part  of  the  abdo- 
men the  pelvis  should  then  be  further  elevated  30  or  more  centimeters  (12  inches) 
above  the  table,  and  the  small  intestines  and  any  redundant  sigmoid  lifted  out  of 
the  pelvic  cavity  and  kept  packed  away  by  non-absorbent  cotton-gauze  pads. 
The  pelvis,  thus  fully  opened  to  view,  is  now  carefully  inspected  to  determine 
the  extent  of  the  disease  on  both  sides,  which  side  is  the  worse,  and  the  exact 
position  and  relations  of  the  uterus  to  the  inflammatory  disease,  and  whether  or 
not  it  will  be  advisable  to  do  a  conservative  operation. 

It  has  become  a  mere  habit  with  many  operators  to  exhibit  surgical  skill  {sic) 
by  removing  uterus,  tubes,  and  ovaries  upon  various  trifling  indications,  such  as  a 
mild  pelvic  peritonitis  with  adhesions,  a  one-sided  suppurative  salpingitis,  etc. 
The  mere  mention  of  such  practices  carries  its  own  condemnation  ;  the  true 
surgeon  will  exercise  a  far  higher  skill  in  wisely  selecting  certain  cases  for  con- 
servatism, and  sparing  all  or  as  much  of  the  pelvic  organs  as  he  deems  sound  or 
capable  of  regeneration  and  a  restored  functional  activity.  To  this  end  an  un- 
usual effort  should  be  made  in  the  case  of  young  women  by  breaking  up  adhe- 
sions, by  plastic  operations,  by  resections,  and  by  the  liberal  use  of  drainage, 
counting  upon  the  remarkable  restorative  powers  of  youth  to  preserve  to 
them  the  possibility  of  conception  and  motherhood ;  or  if  that  is  impossible  and 
the  tubes  must  be  sacrificed,  to  preserve  menstruation  by  leaving  the  uterus  and 


OPERATION.  239 

ovaries ;  or  if  the  uterus  too  must  be  removed,  to  preserve  the  ovaries,  or  one 
ovarj  or  a  piece  of  an  ovary,  to  obviate  as  far  as  possible  the  distressing  sequelae 
of  the  artificial  menopause. 

The  older  the  patient  the  less  these  reasons  will  have  vt'eight ;  often,  too, 
after  long  years  of  invalidism  and  suffering  the  patient  will  insist  that  she  desires 
above  all  other  things  to  be  rid  of  her  pelvic  complaint  at  all  costs ;  in  this  case 
the  surgeon  will  not  assume  the  same  risks  to  save  structures  he  would  other- 
wise feel  fully  justified  in  doing.  In  all  cases  and  at  all  times  the 
natural  bias  of  the  surgeon's  mind  should  be  toward  a 
healthy   conservatism. 

If  it  is  a  case  of  extensive  posterior  pelvic  peritonitis, 
with  long,  veil-like  adhesions,  binding  down  uterus,  ovaries,  and  tubes,  I  begin 
the  enucleation  by  grasping  the  body  of  the  uterus  with  a  pair  of  museau  for- 
ceps and  drawing  it  up  toward  the  lower  angle  of  tlie  incision,  putting  the  adhe- 
sions on  the  stretch.  They  may  yield  readily,  and  if  they  do  I  simply  strip  the 
whole  posterior  surface  of  the  uterus  free  with  my  fingers,  catching  up  and 
breaking  the  bands  one  by  one,  as  near  to  the  uterus  as  possible.  ]^ext,  by 
pulling  the  uterus  to  the  right  and  forward,  the  adhesions  on  the  left  are  made 
tense,  so  that  the  tube  and  ovary  may  easily  be  stripped  loose  and  lifted  up,  free- 
ing the  broad  ligament ;  the  right  side  is  freed  by  reversing  the  movements. 

If  the  adhesions  of  the  posterior  surface  of  the  womb  do  not  yield  readily 
to  the  fingers  the  scissors  must  be  used.  Expose  the  adhesions  by  pulling  the 
uterus  forward  and  holding  the  rectum  back  by  means  of  a  sponge  held  in  the 
forceps  or  with  the  fingers,  and  then  cut  them,  one  after  the  other,  close  to  the 
uterus.  Adhesions  of  the  ovary  and  tube  to  the  rectum  and  j^elvic  wall  may 
also  be  severed  in  this  way. 

When  the  adhesions  are  universal,  dense,  and  close,  the 
surgeon  must  carefully  inspect  the  whole  field  before  beginning  the  enucleation 
at  all,  in  order  to  effect  an  entrance  at  the  point  of  least  resistance.  This  will 
often  be  found  at  the  j)lace  where  the  tubes  dip  down  into  the  posterior  pelvis 
and  are  lost  among  the  adhesions.  By  working  in  first  one  finger  and  then  two, 
and  stripping  from  side  to  side,  a  purchase  is  secured  upon  the  adherent  uterus 
and  the  under  surface  of  the  ovary  and  tube  of  that  side.  In  this  way  dense 
adhesions  frequently  yield  in  a  direction  from  below  upward,  where  it  seemed 
impossible  to  break  through  them  at  the  pelvic  brim. 

In  severing  particularly  dense  adhesions  the  principle  must  always  be  fol- 
lowed of  cutting  closer  to  the  organ  which  is  to  be  removed.  Thus,  in  freeing 
the  uterus  from  the  rectum  in  a  hysterectomy,  a  piece  of  the  uterus  should  be 
left  on  the  bowel  rather  than  risk  wounding  the  rectum  by  trying  to  cut  exactly 
between  the  two. 

In  another  group  of  cases  the  uterus,  ovaries,  and  tubes 
lie  completely  buried  beneath  a  dense  mass  of  adhesions.  Here  the 
uterus  may  be  located  by  first  fixing  the  position  of  the  rectum  and  then  pass- 
ing a  sound  into  the  bladder  to  determine  its  posterior  limit,  and  dissecting  care- 
fully with  knife  and  forceps  and  scissors  between  these  two  points.     Below  the 


240 


HYSTERECTOMY,    WITH    EXTIRPATION    OF    OVARIES   AND   TUBES. 


surface  the  adhesions  often  become  less  dense  and  can  be  separated  by  the 
fingers,  thus  opening  up  a  wide  area  in  which  the  uterus  may  be  found.  Tiie 
dissection  is  continued  until  the  whole  organ  with  its  ovaries  and  tubes  has  been 
freed  and  elevated  out  of  its  bed. 

In  still  another  class  of  cases  the  rectum  is  adherent  to 
the   bladder,  covering    in    uterus,    ovaries,   and    tubes.     This 


Fig.  393. — IlYSTEno-SALPiNGO-OoPHORECTOMV   FOR  Large  Double  Hydrosalpinx  with   Extensive   Ad- 
hesions. 

U^  uterus ;  /",  fundus  ;  R  Z,  round  ligaments ;  T^  uterine  tubes  ;   0^  ovaries.     No.  504.    ^'s  natural  size. 

adhesion  may  also  be  broken  up  and  the  structures  below  freed  by  dissection 
between  the  two,  pulling  the  bladder  forward  and  pushing  the  rectum  back  so 
as  to  make  the  interval  between  the  two  as  wide  as  possible.  If  a  portion  of 
either  viscus  is  to  be  sacrificed  to  make  the  separation,  it  must  be  the  bladder. 

If,  on  account  of  their  density,  it  is  impossible  with  safety  to  break  up  all 
the  adhesions  from  above,  it  is  best  to  proceed  at  once  with  the  first  two  steps 
in  enucleation  by  seeking  out  the  ovarian  vessels,  which  can  always  be 
found  at  the  outer  extremity  of  the  broad  ligament  upon  lifting  up  the  sigmoid 
flexure.  When  these  are  isolated  they  should  be  clamped  on  the  uterine  side 
and  ligated  on  the  pelvic  side  and  cut  between,  the  incision  being  continued  in 
an  oblique  direction  across  to  the  insertion  of  the  round  ligament  into  the  uterus. 
The  round  ligament  is  now  ligated  about  2  centimeters  away  from  the 
uterus  and  clamped  close  to  it  and  divided.  By  this  means  the  top  of  the  broad 
ligament  is  now  cut  completely  through  and  the  adherent  tube  and 
ovary  may  be  reached  from  the  front  and  freed.  This  is 
done  by  first  severing  them  from  the  broad  ligament  and  working  down  toward 
the  pelvic  floor  in  front  of  them,  afterward  dealing  with  the  adhesions 
to  the  pelvic  wall  by  working   from   below   upward. 


OPERATIOX. 


241 


"When  in  any  of  these  groups  of  cases  the  adhesions  are  all  broken  up  and 
the  uterus  with  ovaries  and  tubes  set  free,  I  complete  the  enucleation  bj  the 
following  steps.     Beginning,  say,  on  the  left  side,  these  will  be : 

1.  Left  ovarian  vessels  ligated  and  severed. 

2.  Left  round  ligament  ligated  and  severed. 

3.  Yesico-uterine  peritoneum  freed  from  left  to  right  and  pushed  well  down 
with  the  bladder,  exposing  the  left  uterine  artery. 

4.  Left  uterine  artery  and  veins  tied  in  the  cervical  portion. 

5.  Uterus  amputated  across  cervical  portion. 

6.  Right  uterine  vessels  clamped  above  the  stump. 

7.  Uterus  pulled  up  and  out  and  right  round  ligament  and  ovarian  vessels 
clamped  and  uterus  removed. 

8.  Ligatures  a]3plied  in  place  of  the  clamps  on  the  right  side. 

9.  Cervical  stump  closed. 

10.  Anterior  layers  of  both  broad  ligaments  and  vesical  peritoneum  drawn 
over  the  stump  and  sutured  there. 

I  begin  the  separation  by  seeking  out  the  left  ovarian  vessels  at  the  outer 
extremity  of  the  broad  ligament  under  the  sigmoid  flexure.  The  sigmoid  is 
often  found  dropped  over  into  the 
outer  extremity  of  the  broad  liga- 
ment and  united  to  it  by  numer- 
ous adhesions.  These  may  be  sep- 
arated by  lifting  up  the  sigmoid, 
stretching  them  a  little,  and  sever- 
ing with  scissors.  When  the  vessels 
are  exposed  I  clamp  them  on  the 
uterine  side  and  ligate  them  with 
a  silk  ligature  passed  through  the 
"clear  space"  on  the  pelvic  side 
and  cut  between  in  an  oblique  di- 
rection across  to  the  round  liga- 
ment attachment  of  the  uterus. 
The  incision  must  be  far  enough 
from  the  ligature  (at  least  1  centi- 
meter) to  avoid  the  risk  of  its  shpping  off  the  stumj)  that  is  left.  I  next  lignte 
the  round  ligament  about  2  centimeters  (|  inch)  from  the  uterus  and  clamp  it 
close  to  the  uterus  and  sever  it  too.  By  these  two  incisions  the  top  of  the  broad 
ligament  is  laid  open. 

The  line  of  reflection  of  the  vesical  peritoneum  on  to  the  uterus  begins  just 
below  the  round  ligament  and  dips  down  into  the  pelvis  and  extends  in  a  con- 
cave line  across  to  the  opposite  side.  If  not  distinguished  at  once  by  the  marked 
contrast  l)etween  the  dark-red  color  of  the  uterus  and  the  whiter  vesical  perito- 
neum, it  will  be  found  by  lifting  up  the  l)ladder  with  forceps  and  noting  the 
line  which  marks  the  limit  between  the  moval)le  portion  on  the  bladder  and  the 
flxed  portion  on  the  uterus. 


Fig.  394, — Oiti.ixe  showing  Extirpation  of  the  Ute- 
rus, Ti'BEs,  AND  Ovaries  by  a  Continuous  Incision 
in  the  Direction  of  the  Arrows,  or  the  Kevekse. 

In  case  the  ovaries  arc  left,  as  they  must  be  in  a  young 
woman  if  they  are  sound,  the  lisration  be^rins  at  the  tubo- 
ovarian  fimbria,  between  the  tube  and  the  ovary. 


242 


HYSTERECTOMY,    WITH    EXTIRPATION   OF   OVARIES   AND   TUBES. 


There  is  often  found  a  false  line  of  apparent  reflection  of  the  vesical  perito- 
neum high  up  on  the  fundus  formed  by  peritoneal  adhesions ;  when  this  is  dis- 
sected away  from  the  uterus  the  real  line  of  reflection  is  evident. 

I  now  detach  the  vesical  peritoneum  along  this  line,  beginning  at  the  left 
round  ligament  and  continuing  the  incision  in  a  concave  line  down  across  the 
front  of  the  uterus  around  to  the  right  round  ligament.  Then,  grasping  uterus, 
ovary,  and  tube  in  the  left  hand,  or  with  museau  forceps,  I  draw  them  strongly 
upward,  outward,  and  toward  the  opposite  side,  while  with  the  right  hand  I 
push  the  vesical  peritoneum  down  off  the  cervix  with  a  firm  sponge  held  in  a 
pair  of  forceps.  The  force  of  the  push  and  peeling  movement  with  the  sponge 
must  fall  upon  the  uterus  and  not  on  the  bladder.  The  separation  of  the  blad- 
der from  the  cervix  is  easily  effected  in  this  way,  exposing  the  uterine  arteries 
and  veins  low  down  in  the  angle  between  vagina  and  cervix.     After  baring  the 


Fig.  30".. 


iiiATioN  OF  Uterus,  Tubes,  and  Ovaries  for  Pelvic  Peritonitis. 


The  right  ovary  contains  two  small  Graafian  follicle  cysts.     The  left  tube  and  ovary  are  converted  into 
a  ragged  njass  by  the  adhesions.     %  natural  size. 


cervix  for  about  3  centimeters  I  take  it  up  between  the  thumb  and  the  fore- 
finger in  front  and  behind  and  seek  out  its  lower  end,  which  can  be  readily  dis- 
tinguished through  the  vaginal  vault.  In  the  same  way,  palpating  at  the  side  of 
the  cervix,  I  easily  recognize  the  uterine  artery  by  its  pulsations.  This  I  now 
ligate  by  a  medium-sized  silk  suture,  carried  beneath  the  vessels  from  before 
backward,  low  down  and  close  to  the  cervix.  Having  now  placed  all 
the  uterine  vessels  on  the  left  side  under  control,  I  proceed  to  amputate  the 
cervix  with  a  hysterectomy  spud  or  a  sharp  scalpel,  cupping  it  slightly  and 
angling  the  cut  off  on  the  right  side  to  a  little  higher  level. 

While  this  is  being  done  the  uterus  is  drawn  strongly  upward,  grasped  by  a 
gauze  pad  or  museau  forceps,  keeping  the  tissues  to  be  cut  always  under  ten- 
sion, so  that  as  soon  as  the  division  of  the  cervix  is  completed  the  two  parts 


OPERATION.  243 

begin  to  separate  until  an  interval  of  two  or  three  centimeters  exists  between 
them,  in  which  the  riglit  uterine  vessel  may  be  seen.  These  are  now  clamped 
and  controlled  a  centimeter  or  more  above  the  cervical  stump,  and  the  uterus 
pulled  still  farther  up  until  the  round  ligament  is  clamped  and  divided  near  the 
fundus  ;  last  of  all,  the  ovarian  vessels  in  the  ligament  near  the  pelvic  brim 
are  clamped  and  cut,  when  the  enucleation  is  complete. 

As  soon  as  the  cervix  is  cut  across  it  is  best  to  wipe  out  the  canal  below 
with  gauze  or  to  push  a  small  piece  of  iodoform  gauze  through  the  canal 
into  the  vagina  in  order  to  cleanse  it ;  the  uterine  cavity  must  also  be  prevented 
from  emptying  its  contents  over  the  wound  by  laying  a  thick  piece  of  gauze 
under  it. 

In  dealing  with  pus  cases  it  is  my  habit  to  tie  a  thick  gauze  bag  over  the  tube 
and  ovary  as  soon  as  they  are  freed  and  lifted  up,  so  as  to  avoid  the  constant 
handling  and  possible  distribution  of  any  of  their  escaping  contents  over  the 
pelvic  peritoneum  during  the  operation. 

One  of  the  most  signal  advantages  secured  by  this  method 
of  extirpation  is  the  increased  ease  with  which  the  enu- 
cleation can  often  be  effected  by  attacking  the  adherent 
masses  from  below  instead  of  in  the  usual  way  from  above,  an  advan- 
tage similar  to  that  claimed  by  the  operation  of  vaginal  hystero-salpingo-oopho- 
rectomy. 

In  order  to  gain  this  advantage  the  enucleation  must  be  begun 
on  the  side,  right  or  left,  which  is  least  adherent,  and  the 
opposite  side  is  not  touched  until  the  cervix  is  divided  and  its  vessels  clamped  ; 
then  the  enucleation  of  this  side  too  is  effected  by  beginning  behind  the  broad 
ligament,  but  in  front  of  the  mass,  low  down  near  the  pelvic  floor,  and 
so  working  it  free  from  below  upward.  It  is  often  astonishing  how  easy  it  is  to 
roll  an  adherent  mass  up  and  out  of  the  abdominal  incision  in  this  way,  though 
the  same  mass  niay  present  grave  difficulties  with  intestinal  and  other  adhe- 
sions when  attacked  from  above.  Any  cystic  masses  in  ovaries  or  uterine  tubes 
should  always  be  evacuated  with  an  aspirator  before  freeing  them,  both  in  order 
to  protect  the  peritoneum  from  their  contents  as  well  as  to  afford  more  room  in 
dealino'  with  them. 

With  the  removal  of  the  uterus  and  its  attached  organs,  the  cerv^ical  stump 
drops  back  to  the  floor  of  the  pelvis. 

The  right  uterine  and  ovarian  vessels  are  tied  with  silk  and  the  round  liga- 
ment with  catgut  and  the  forceps  removed.  In  applying  the  ligature  to  the 
uterine  vessels  care  must  be  taken  not  to  carry  the  loop  deep  down  beside  the 
cervix,  so  as  to  avoid  including  the  ureter.  The  vessels  which  are  clamped 
above  the  cervix  can  be  seen  and  tied  at  a  safe  level  above  the  base  of 
the  broad  ligament. 

There  is  now  seen  on  the  pelvic  floor  a  crescentic  denudation,  broad  in  the 
middle,  and  tapering  to  its  horns  at  either  pelvic  brim,  at  the  stump  of  the 
ovarian  vessels.  In  the  center  lies  the  cervical  stump.  I  do  not  in  any  way 
disinfect   or  burn  out  the  cervical  canal  or  the  surface  of  the  stum])   unless 


244  HYSTERECTOMY,    WITH    EXTIRPATION"    OF    OVARIES    AXD   TUBES. 

there  has  been  a  purulent  uterine  discharge.  It  is  sufficient  simply  to  wipe  the 
stump  out  clean  with  gauze. 

I  now  approximate  the  surface  of  the  stump  for  two  purposes — to  shut  off 
communication  with  the  vagina  through  the  canal,  and  to  check  any  slight 
hemorrhage.  For  this  purpose  I  use  from  four  to  six  catgut  sutures,  entering 
the  first  suture  in  the  middle  of  the  anterior  lip,  not  including  the  reflected 
vesical  peritoneum,  and  bringing  it  out  near  the  cervical  canal,  to  re-enter  be- 
hind the  canal,  and  come  out  again  on  the  posterior  peritoneal  surface  of  the 
stump.  This  suture  is  tied  tight  at  once,  and  brings  the  lips  of  the  stump 
together  in  the  middle;  it  should  be  left  long,  to  serve  as  a  tractor,  to  hold 
the  stump  within  easy  reach,  while  the  remaining  sutures  are  introduced  on 
either  side  of  it. 

If  any  bleeding  vessels  are  seen  on  the  surface  of  the  stump,  sutures  should 
be  passed  through  the  lips  in  such  a  manner  as  to  catch  and  control  them  when 
tied.  Two  or  three  sutures  on  each  side  make  an  accurate  approximation,  like 
the  lips  of  a  purse.  All  the  sutures  are  now  cut  short  and  the  stump  dropped 
back.  The  whole  raw  crescent-shaped  area  between  the  peritoneal  folds  must 
now  be  inspected  under  a  good  illumination  to  see  if  there  is  any  bleeding.  If 
there  is,  it  must  be  checked,  catching  the  point  up  with  forceps  and  applying 
a  ligature. 

Finally,  I  unite  the  anterior  peritoneal  layers  of  the  broad  ligaments  and 
the  reflected  vesical  peritoneum  to  the  posterior  peritoneum  by  a  continuous 
catgut  suture,  so  as  to  cover  in  the  whole  raw  area,  together  with  the  cervical 
stump.  This  suture  begins  by  turning  in  the  ovarian  stumps,  and  pierces  the 
peritoneum  at  points  about  1  centimeter  apart.  Upon  reaching  the  cervical 
stump  the  vesical  peritoneum  is  attached  to  its  posterior  peritoneal  surface.  If 
this  long  suture  is  snugly  dra\vn  up  each  time  it  is  passed,  it  lifts  the  peri- 
toneum up  in  the  pelvis,  and  tends  to  stop  any  slight  oozing  from  the  edges  of 
the  wound. 

It  is  essential,  before  closing  the  wound  by  uniting  anterior  to  posterior 
peritoneum,  to  stop  all  bleeding ;  if  this  is  not  done  a  hematoma  may  form 
which  may  give  rise  to  an  abscess  and  necessitate  the  dilatation  of  the  cervix  by 
the  vagina  to  secure  its  evacuation  and  drainage.  If  there  is  a  wide  area  of 
cellular  tissue  exposed,  and  it  tends  to  ooze,  it  will  be  better  to  close  the  peri- 
toneum with  mattress  sutures,  so  as  to  let  the  blood  and  serum  escape  and  be 
absorbed. 

The  pelvis  after  the  extirpation  is  completed  presents  to  view  only  the 
bladder  and  the  rectum  with  a  line  of  accurately  united  peritoneum  stretching 
in  a  concave  line  between  them. 

The  incision  in  the  abdomen  is  completely  closed  and  the  dressing  ap- 
plied. 

Complications. — The  complications  met  with  in  the  inflammatory  group  of 
cases  of  this  class  are  probably  more  serious  than  in  any  other  group  in  ab- 
dominal surgery ;  out  of  the  histories  of  my  one  hundred  cases  the  following 
have  been  collated  : 


COMPLICATIONS.  245 

Cases. 

Omental  adhesions  in 45 

Intestinal  adhesions  in 52 

Adhesions  of  the  vermiform  appendix  in 27 

Sigmoid  flexure  adhesions  in 32 

Bladder  adhesions  in 31 

The  rupture  of  a  pus  sac  with  the  escape  of  pus  into  the  peritoneal  cavity 

occurred  in 27 

The  intestines  were  injured  in  varying  degrees  from  a  laceration  of  the  external 

coat  to  a  complete  rupture  of  all  the  coats  in 24 

Old  fistulous  tracts  were  found  opening  into  the  intestine  and  requiring  suture 

to  close  them  in 4 

A  partial  obstruction  of  the  intestine  existed  in 3 

It  was  the  fashion  to  use  drainage  during  the  period  in  which  most  of  tliese 
operations  were  performed,  and  I  must  therefore  note  thirty-one  cases  drained 
through  the  abdominal  wound  and  fifteen  drained  througli  the  cervix. 

The  mortality  in  this  entire  series  amounted  to  four  per  cent ;  one  of 
the  deaths  was  due  to  an  infection  entering  along  the  drainage  tract,  another 
was  caused  by  peritonitis  from  the  rupture  of  the  intestine  at  the  site  of  the 
suture,  another  was  due  to  a  purulent  peritonitis,  and  the  fourth  came  from 
an  intestinal  obstruction  at  the  site  of  an  old  dense  annular  cicatrix  in  the 
sifijmoid  flexure. 


67 


CHAPTER  XXIX. 

OVARIOTOMY. 

1.  Ovarian  tumors  in  general.     1.  Kinds  of  ovarian  tumors.     2.  Relative  frequency.    3.  Benign 

and  malignant  tumors.  4.  The  pedicle :  {a)  Long  pedicle,  (b)  No  pedicle  at  all.  (c)  Ro- 
tation of  pedicle.  5.  Rupture  of  a  cyst.  6.  Clinical  course.  7.  Diagnosis :  («)  Is  a  tumor 
present?    (b)  Is  it  an  ovarian  tumor!    (c)  Of  what  kindf 

2.  Multilocular  ovarian  cyst-adenonui.      1.  Pathology  :    («)   Contained  fluid,     (b)    Pseudomucin. 

2.  Development.     3.  Cause.     4.  Symptoms. 

3.  Papillary  tumors  of  the  ovary.     1.  Introductory:  (a)  Forms,     (b)  Relative  malignancy  of  papil- 

lomata  and  carcinomata.  (c)  Clinical  characteristics,  (d)  Histology,  (e)  Diagnosis.  2. 
Papillary  parovarian  cyst.  3.  Papillary  cystic  Graafian  follicle.  4.  Pseudomucinous 
papillary  adenoma.  5.  Simple  papillary  adenoma.  6.  Papillary  adeno-carcinoma.  7. 
Papillary  cyst-adeno-sarcoma. 

4.  Carcinomata  of  the  ovary. 

5.  Dermoid  cysts  of  the  ovary. 

6.  Parovarian  cysts.     Hydatid  of  Morgagni. 

7.  Fibroid  tumors  of  the  ovary. 

8.  Sarcomata  of  the  ovary. 

9.  Treatment  of  ovarian  tumors.     1.  Contraindications  to  operation.     2.  Steps  of  operation :  (a) 

Median  abdominal  incision,  (b)  Evacuation  and  withdrawal  of  the  cyst,  (c)  Liberation 
of  all  adhesions,  (d)  Ligation  of  pedicle,  (e)  Intraligamentary  cysts.  (/)  Examination 
of  opposite  ovary,     (g)  Cleansing  peritoneum,  if  soiled.     (/;)  Closure  of  incision. 

Ovarian  Tumors  in  General. — The  ovarj,  although  but  a  diminutive  organ,  i& 
peculiarly  rich  in  cellular  elements  of  various  kinds  which  may  give  rise  to  a 
great  variety  of  tumors ;  it  is  difficult  also  to  dissociate  mentally  the  wonderful 
function  of  the  ovary  as  a  reproductive  organ  from  its  marvelous  activity  as  an 
atypical  tissue  producer  when  once  its  activities  have  become  perverted. 

We  find,  therefore,  in  the  ovary  retention  cysts,  epitheliomata  (using  the 
word  broadly  to  include  adenomata  as  well),  connective-tissue  tumors,  fetal  in- 
clusion cysts,  and  parovarian  cysts,  though  the  last  are  not,  strictly  speaking, 
ovarian. 

The  first  group,  the  retention  cysts,  include : 
Cystic  Graafian  follicles  of  large  size. 
Cystic  corpora  lutea,  and 
Multiple  cystic  follicles,  usually  small  in  size. 
The  epithelial  group  of  tumors  include  : 

The  cyst-adenomata,  which  are  the  classical  ovarian  tumors, 
Papillary  ovarian  tumors,  and 
Adeno-carcinomata. 
The  connective-tissue  group  is  made  up  of : 
Fibroid  tumors  of  the  ovary, 
Myomata,  and 
Sarcomata. 

246 


OVARIAN"   TUMORS    IN"    GENERAL.  247 

Dermoid  tumors  stand  alone  as  a  peculiar  group  formed  by  inclusions 
of  a  part  of  the  ectoderm  during  the  development  of  the  ovary. 

Parovarian  cysts,  while  not  strictly  belonging  to  the  group  of  ovarian 
tumors,  are  most  naturally  associated  with  them  for  important  clinical  reasons. 

Retention  cysts  of  the  ovary  are  not  considered  in  this  chapter,  as  they  have 
been  placed  among  those  affections  which  are  best  treated  by  conservatism.  I 
would  also  exclude  here  all  of  the  small  and  all  of  the  clear-walled  parovarian 
cysts  found  associated  with  a  sound  ovary  ;  these  will  be  found  in  the  chapter  on 
conservatism. 

The  relative  frequency  of  the  different  kinds  of  ovarian  tumors 
varies  greatly.  Taking  1-11  cases  of  large  tumors  of  the  ovary  differen- 
tiated macroscopically  in  the  operating  room,  they  were 
grouped  as  follows  : 

Multilocular  ovarian  cysts 38 

Unilocular  ovarian  cysts 36 

Parovarian  cysts ....    23 

Papillary  tumors 20 

Dermoid  cysts 25 

A  thorough  sifting  of  this  material,  however,  in  the  pathological  laboratory 
has  served  to  demonstrate  the  necessity  of  a  careful  microscopical 
examination  in  every  case;  by  doing  this,  small  dermoid  cysts  were 
discovered  where  none  were  suspected  on  account  of  their  diminutive  size,  and 
inflammatory  masses  were  sometimes  found  to  be  due  to  dermoids  which  had 
discharged  their  contents  and  which  only  revealed  their  true  character  when  the 
minute  cell  elements  were  studied. 

The  group  of  paj^illary  cysts  was  also  enlarged  by  a  microscopic  examina- 
tion at  the  expense  of  the  multilocular  and  the  unilocular  cysts. 

The  group  of  unilocular  cysts  of  the  ovary,  when  more  carefully  studied, 
was  diminished  by  the  discovery  of  small  cysts  in  the  walls ;  these  tumors  were 
therefore  in  most  instances  reclassified  among  the  multilocular  cysts ;  such  a 
reclassification  was  also  made  necessary  by  the  frequent  discovery  of  trabeculae 
on  the  inner  cyst  wall.  These  were  clearly  the  remains  of  partitions  between 
originally  separate  cysts  which  later  become  fused  by  pressure  and  atrophy  of 
the  septa  or  by  spontaneous  rupture  from  tension. 

In  marked  contrast,  therefore,  to  the  group  of  tumors  classified  by  their 
purely  macroscopic  appearances,  I  present  another  group  of  138  cases  of  large 
ovarian  tumors,  every  one  of  which  was  examined  microscopically; 
they  were  found  to  be  distributed  as  follows : 

Multilocular  adcno-cy stoma. .    57 

Unilocular  adeno-cystoma 3 

Adeno-papilloina 27 

Adeno-carcinoma 9 

Sarcoma 2 

Fibroma 4 

Dermoid  cysts 26 

Parovarian  cysts 10 


248 


OVARIOTOMY. 


It  is  only  necessary  to  contrast  these  two  lists  to  demonstrate  the  necessity 
of  a  searching  miscroscopic  examination  in  every  case  in  order  to  establish  the 
diagrnosis  on  a  scientific  footino;. 

A  further  most  important  clinical  classification  of  the 
ovarian  tumors  is  into  benign,  malignant,  and  s e m i  - m a  1  i g - 
nant.  It  must  always  be  borne  in  mind  that  these  terms  are  only  clinical  ex- 
pressions and  are  therefore  vague  ;  by  a  benign  tumor  is  meant  one  which  does 
not  tend  to  recur  when  extirpated,  as  well  as  one  which  does  not  tend  to  implant 
itself  elsewhere  or  to  invade  the  tissues ;  by  a  malignant  tumor  is  meant  one 
which  tends  to  destroy  life  by  invasion  of  the  surrounding  and  subjacent  tissues, 
as  well  as  one  which  distributes  its  elements  by  metastases  to  other  parts  of  the 
body ;  a  semi-malignant  tumor  is  one  which  may  extend  to  the  adjacent  parts 
by  implantation,  and  then  may  or  may  not  continue  to  grow  after  the  removal  of 
the  parent  tumor. 

In  general,  the  multilocular  cyst-adenomata,  the  dermoids,  the  fibroids,  and 
the  parovarian  cysts  are  classified  as  benign,  the  papillary  tumors  as  semi-malig- 
nant, and  the  carcinomata  and  the  sarcomata  as  malignant. 

The  essential  weakness  of  such  a  clinical  classification  is  shown  histologically 
by  the  recognition  that  many  of  the  cyst-adenomata  are  in  reality  papillary  tu- 
mors, and  many  of  the  papillomata  belong  to  the  carcinomata,  and  sometimes 

even  to  the  sarcomata. 

From  a  practical  stand- 
point all  ovarian  tumors 
must  be  considered  as  ma- 
lignant until  removed  and 
proved   otherwise. 

Pedicle.— Ovarian  tumors  are  at- 
tached to  the  broad  ligament  by  the 
same  anatomical  structures  by  which 
the  normal  ovary  is  found  attached  to 
it.  The  base  of  attachment  of  the  tu- 
mor is  called  its  pedicle,  and  in  this 
pedicle  the  various  anatomical  ele- 
ments differ  greatly  in  their  mutual 
relations,  according  to  the  mode  of 
growth  of  the  tumor,  whether  up  into 
the  abdomen  or  down  toward  the  pel- 
vic floor,  according  to  its  length,  and 
according  as  it  has  a  broad  or  a  nar- 
row insertion. 

The  anatomical  structures  con- 
cerned are  the  mesovarium,  the  utero-ovarian  ligament,  the  mesosalpinx,  the 
uterine  tube,  and  the  broad  ligament ;  they  deserve  careful  consideration  in 
each  case,  because  the  correct  diagnosis  in  any  given  case  depends  upon  the 
recognition  of  the  relationship  between  the  tumor  and  the  broad  ligament  and 


felvl 


Fig.  396. — -Diagram  showing  the  Kelations  of 
AN  OvARiAx  Cyst  to  the  Peritoneum  of  the 
Pelvic  Floor  and  Broad  Ligament. 

FT^  the  uterine  tube,  with  its  intact  mesosalpin.x 
(i/«).  The  red  line  (/*,  1')  is  the  peritoneum,  wliieh 
extends  to  the  hilurn  of  the  ovary,  but  does  not 
cover  it. 


PEDICLE.  249' 

the  uterus  as  established  by  means  of  the  pedicle ;  the  treatment,  also,  is  sim- 
plified or  rendered  difficult  according  to  the  character  of  the  pedicle  and  the 
relations  of  its  component  structures. 

In  some  instances  the  mesovarium  is  pulled  out  with  the  utero-ovarian  liga- 
ment in  the  form  of  a  long  band  to  form  a  pedicle  6  or  8  or  more  centimeters 


Fio.  397. — LoxG  Fedicle  of  a  Papillary  Ovariax  Adeno-cystoma. 

The  tutie  is  above,  with  a  cyst  (hydatid  of  Morgagnij  under  its  fimbriated  extremity.     March  8,  1894. 
No.  202.     %  natural  size. 

in  length  (see  Fig.  397).  At  other  times  the  tumor  (usually  parovarian)  de- 
velops in  the  outer  part  of  the  mesosalpinx,  and  the  ampullar  part  of  the  tube 
is  spread  out  on  its  surface.  When  the  whole  mesosalpinx  is  spread  apart  by 
the  growing  tumor,  the  entire  tube  is  also  stretched  out  on  its  surface  from 
cornu  uteri  to  fimbriated  end,  and  may  be  greatly  lengthened  (see  Fig.  398). 
Continued  development  in  this  direction  opens  up  the  lower  part  of  the  broad 
ligament,  and  then  raises  the  pelvic  and  sometimes  the  abdominal  peritoneum, 
even  as  high  up  as  the  celiac  axis.  In  broad  ligament  tumors  of  this  kind  the 
uterus  is  found  lying  closely  attached  on  one  side. 

In  marked  contrast  to  these  tumors  which  lie  between  the  layers  of  the  broad 
ligament,  a  pse  ud  o  -  intral  igamen  tary  tumor  may  be  found  when  an 
ovarian  tumor  the  size  of  a  fist  or  a  child's  head  is  caught  in  the  pelvis  under 
the  tube  and  mesosalpinx  which  it  pushes  up  before  it,  so  that  the  mesosalpinx 
covers  the  tumor  in  like  a  hood ;  the  same  effect  may  also  be  produced  by 


250 


OVARIOTOMY. 


adhesions  to  the  broad  ligament  and  mesosalpinx  covering  in  the  tumor  (Paw- 
hk).     (See  Fig.  399.) 

Rotation  of  the  Pedicle . — Spherical  non-adherent  cysts  with  a  long 
pedicle  are  peculiarly  liable  to  an  accidental  rotation  and  strangulation  of  the 
pedicle,  checking  the  venous  outflow  from  the  tumor  and  causing  hemorrhage 
into  its  interior,  sometimes  large  enough  to  cause  the  sudden  collapse  and  death 
of  the  patient.  If  the  woman  survives  such  an  accident  and  the  rotation  contin- 
ues, the  entire  blood  supply  may  be  cut 
Ms.  off  and  the  cyst  become  gangrenous. 


Fig.  398. — Diagram  showing  the  Kelations  of  an 
Intraligamentaby  Cyst  to  the  Anterior  and 
Posterior  Layers  of  the  Peritoneum  of  the 
Broad  Ligament. 

The  red  line  (P,  P)  is  the  peritoneum,  of  which 
J/s,  Mh  is  the  mesosalpinx,  whose  layers  are  widely 
separated,  while  the  uterine  tube  {FT)  is  spread  out 
flat  on  its  surface. 


P.F 

Fig.  399. — Adherent  Cyst  of  the  Ovart  show- 
ing the  Mimicry  of  the  Intraligamentaby 
Cyst. 

The  uterine  tube  (F  T),  the  mesosalpinx  (Ms), 
and  the  pelvic  peritoneum  (P,  PF,  P)  are  adherent 
to  the  cyst  on  all  sides.  The  dotted  line  and  the 
arrow  indicate  the  level  of  the  pelvic  brim. 


The  symptoms  of  strangulation  are  sudden  pain,  pallor,  and  sometimes  faint- 
ing with  sudden  enlargement  of  the  tumor,  which  becomes  tense  and  painful. 

If  the  woman  survives  the  first  attack  the  symptoms  may  be  progressive  and 
she  is  confined  to  bed,  and  peritonitis  supervenes  ;  later,  the  cyst,  originally  free, 
is  found  invested  on  all  sides  with  adhesions.  Suppuration  may  follow,  marked 
by  chills  and  high  temperature. 

With  the  cutting  off  of  the  blood  supply  and  the  pouring  out  of  a  hemor- 
rhage into  the  interior  of  the  cyst,  the  tumor  assumes  more  the  nature  of  a 
foreign  body,  exciting  a  violent  reactive  inflammation  in  all  contiguous  parts 
of  the  peritoneum,  and  becoming  attached  to  it  by  vascular  adhesions,  which 
in  time  more  or  less  replace  the  normal  blood  supply.  In  rare  cases  the  pedicle 
may  atrophy  and  become  detached,  leaving  the  tumor  to  continue  a  para- 
sitic existence.  A  remarkable  instance  of  this  sort  is  shown  in  Fig.  400, 
in  the  inset,  and  in  Fig.  403  in  the  text.  There  was  ascites  in  the  abdomen 
and  extensive  peritoneal  carcinosis,  and  the  cyst,  which  could  not  be  removed 
on  this  account,  was  asj^irated. 

In  one  of  my  cases  of  hemorrhage,  figured  in  the  text,  there  was  a  large  accu- 
mulation of  blood  just  above  the  twisted  pedicle  and  in  the  walls  of  the  adjacent 


Fio.  400. — Parasitic  Ovakian  Cyst 


E  -WITH  General  Peritoneal  Carcinosis. 


The  cyst  is  rolled  ui>\vard,  showing  its  under  surface  and  the  atrophied  pedicle  with  the  tube.  In  the 
place  of  the  left  appendage  in  the  pelvis  is  seen  the  uterine  end  of  the  pedicle  of  the  cyst.  Ob.<erve  the  oval 
opening  in  the  broad  ligament;  the  upper  border  of  this  opening  is  formed  by  the  uterine  end  of  the  tube, 
while  the  stump  of  the  ovarian  ligament  is  visible  through  the  opening;  both  stumps  merge  into  the  peri- 
toneal covering.     The  external  iliac  vessels,  right  ovary,  and  tube  adherent.     Jsov.  6,  1897. 


Thickened  Woody  portion 

ofc_yst 
on  pelv.  floor.    ' 


Round  iig.  '  Al)d.ead 


Twisted  pedicle 


Fig.  401. — Left  Ovarian  Cyst  with  a  Twisted   Pedicle,  including  the  Uterine   Tube,  the   Ovarian 

Ligament,  and  the  Round  Ligament. 

The  area  of  hemorrhagic  infarction  is  well  shown  in  the  pedicle  and  the  adjacent  cyst  wall.     July  16, 
1894.    No.  2910.    %  natural  size. 


Fig.  402. — Pedicle   untwisted  to   show  its   Anatomical   Elements,  the   Extent  to  which  the  Kound 
Ligament  is  Involved,  and  the  Hemorrhagic  Infarct.    %  Natural  Size. 


PEDICLE. 


251 


part  of  the  cjst.     In  this  case  the  short  pedicle  in  twisting  occhided  the  uterine 
tube  and,  what  is  quite  rare,  the  round  ligament  was  drawn  up  into  the  twist. 


Adh  carciTioTTiatous 
ome.r\ihm    ^ 


Adh-inesenfeTy 

of 

small  intest. 


AirophieoL     \:| 
pedicle  of  cyst 


Fig.  403. — The  Relations  of  the  Parasitic  Multilocclab  Ovarian  Cvst  shown  in  Inset  Fig.  400. 


The  uterus  lies  below  the  cyst  in  the  pelvis  and  totally  disconnected  from  it;  the  atrojiliied  detached 
pedicle  lies  above  tiie  bladder.  The  cyst  is,  as  shown,  extensively  adherent  to  the  posterior  peritoueuni, 
mesentery,  colon,  and  omentum.     Nov.  6,  1897.     (Autopsy.) 

Prof.  O.  Kustner  {Centralh.  f.  Gyn.,  1891,  No.  11)  believes  that  the  tu- 
mors of  the  right  side,  as  a  rule,  rotate  from  left  to  right,  while  left  ovarian 
tumors  turn  from  right  to  left.     In  four  tumors  of  the  right  ovary  he  found  the 


252 


OVARIOTOMY. 


twisting  in  every  case  following  this  rule,  and  in  six  left-sided  tumors  he  found 
the  rule  to  hold  in  five  cases. 

I  find  two  causes  for  the  rotation  of  cysts.  In  the  first  place,  large  multi- 
locular  cysts  exhibit  a  notable  tendency  to  the  formation  of  one  large  cyst 
cavity,  with  a  number  of  subsidiary  ones,  and  the  tumor  will  invariably  turn 
until  the  convex  surface  of  the  large  cyst  comes  to  lie  in  relation  to  the  con- 
cavity of  the  distended  anterior  abdominal  wall ;  this  produces  a  partial  rotation 
which  does  not  tend  to  increase.  I  think  the  cases  in  which  the  rotation 
amounts  to  or  exceeds  one  turn,  found  in  the  spherical  tumors  the  size  of  a 
man's  head,  are  for  the  most  part  due  to  the  alternate  relaxations  and  contrac- 
tions of  the  anterior  abdominal  walls  acting  most  decidedly  on  the  part  of  the 
tumor  which  is  nearest  the  median  line. 

Rupture  of  a  Cyst. — Rupture  of  an  ovarian  cyst  occurs  when  its  walls  have 
been  distended  and  thinned  out,  or  when  suflicient  force  is  applied  by  a  blow  or 
by  the  powerful  contraction  of  the  abdominal  muscles. 

In  the  polycystic  tumors  the  rupture  of  one  cyst  into  another  is  a  matter  of 
regular  occurrence,  and  in  this  way  many  smaller  loculi  fuse  to  form  the  main 
cyst  cavities  so  commonly  found ;  the  cyst  walls  are  delicate  and  either  rupture 
by  the  increased  tension  of  their  contents  or  by  absorption  of  their  septa  from 
mutual  pressure.  Rupture  into  the  abdominal  cavity  is  most  apt  to  occur  in 
the  thin-walled  cysts,  such  as  some  cyst-adenomata  and  parovarian  cysts ;  be- 
cause of  their  thick  walls,  dermoid  tumors  are  but  rarely  ruptured  unless  from 
a  violent  blow. 

As  a  result  of  the  severe  accidents  to  which  women  with  large  tumors  seem 
peculiarly  liable,  such  as  falling  down  stairs  or  from  a  chair,  etc.,  any  sort  of  a 

cystic  tumor  may  rupture. 

The  rupture  is  commonly 
found  as  a  rent  in  the  capsule, 
and  if  this  happens  to  open  a 
large  blood  vessel,  death  from 
intraperitoneal  hemorrhage  may 
shortly  take  place.  Fortunate- 
ly, such  an  occurrence  is  rare, 
and  the  only  effect  produced  is 
to  pour  the  cyst  contents  into 
the  abdominal  cavity,  where, 
if  it  is  of  a  bland  nature,  as  in 
the  case  of  most  parovarian 
cysts,  it  is  rapidly  absorbed  and 


thrown   off  with  an   enormous 

lous   Pseudomucinous   Secretion   pouring        polyuria    lasting    One     Or    mOre 
Abdominal  Cavity.     Dec.  23,  1895.     Nat-  i      '  t-C   xi,      j    •  i   •         x     „    •_ 

'  davs.     li  the  nuid  is  of  an  ir- 


Fio.   404. — Ovarian   Cyst   showing  Natural   Perforation 
AND   a   Tenac 
out  into  the 
URAL  Size. 


ritating  nature,  a  sharp  attack 
of  peritonitis  with  adhesions  may  result ;  when  the  cyst  contains  papillary 
elements,  these   are   disseminated  all  over  the   peritoneum,  where  they  con- 


Fig.  405. — Laroe  Multiloculab  Ovarian  Cyst  in  a  Negress. 
Aspiration.     Death  without  operation.     Autopsy. 


DIAGNOSIS.  253 

tinue  to  grow  and  an  ascites  forms,  and  ultimately  the  patient  dies  of  ex- 
haustion. 

After  a  time  the  walls  of  the  ruptured  cyst  retract,  forming  dense  cicatricial 
bands  and  exposing  and  everting  any  secondary  cysts  contained  within  the  cavity. 

A  rare  form  of  rupture  is  a  little  pinched-out  hole  from  which  the  tough 
pseudo-mucinous  fluid  slowly  oozes  out  in  a  tenacious  rope. 

In  one  of  my  cases  the  hole  was  plugged  from  within  by  a  little  flaccid  cyst 
seen  hanging  from  the  outer  surface  of  the  tumor. 

Clinical  Course. — The  tendency  of  all  ovarian  tumors  is  to  grow  larger, 
filling  first  the  posterior  quadrant  of  the  pelvis  of  the  side  from  which  they 
spring,  then  filling  the  whole  pelvis,  and  finally  rising  up  into  the  abdomen 
and  gradually  encroaching  upon  its  cavity  in  a  direction  from  below  upward. 

Tumors  weighing  over  fifty  pounds  are  rare,  but  well-authenticated  cases  are 
recorded  in  which  the  weight  has  exceeded  one  hundred  and  fifty  pounds. 

The  smaller  tumors  displace  the  uterus  at  first  by  pushing  it  to  the  opposite 
side,  then  by  traction  on  the  pedicle  they  draw  it  toward  the  side  to  which  the 
tumor  is  attached  (see  Vol.  I,  Figs.  73  and  74) ;  if  the  uterus  is  adherent  it 
may  be  drawn  up  into  the  abdomen  as  the  tumor  enlarges  (a  s  c  e  n  s  u  s   uteri). 

The  bladder  is  displaced,  at  first  becoming  gibbous  and  next  expanding  up- 
ward into  the  abdomen  ;  when  small  tumors  are  adherent  or  when  larger  ones 
press  on  the  pelvic  fioor  and  on  the  brim,  the  ureters  are  often  compressed,  pro- 
ducing a  hydroureter  of  low  grade. 

The  rectum  is  also  compressed,  and  in  the  large  tumors  the  other  intestines 
are  crowded  up  under  the  ribs  and  out  at  -the  sides,  and  digestion  is  much  inter- 
fered with. 

The  largest  tumors  also  find  room  for  their  contents  by  pushing  out  the 
abdominal  wall  until  it  hangs  pendulous,  even  covering  the  knees,  and  by  spread- 
ing out  the  margins  of  the  ribs  like  great  wings  (a  late  chest).  Patients 
thus  aifiicted  often  have  marked  edema  of  the  legs,  and  suffer  so  from  the 
weight  and  from  dyspnea  that  they  rarely  leave  their  l)edroom,  and  are  often 
compelled  to  live  in  a  chair  so  as  to  be  able  to  breathe  (see  Fig.  405). 

Diagnosis. — In  making  a  diagnosis  of  an  ovarian  tumor,  three  questions 
must  be  answered  when  possible  :  (a)  Is  there  a  tumor  present  ?  (b)  Does  it 
occupy  the  place  of  the  ovary  ?     (c)  What  kind  of  an  ovarian  tumor  is  it  ? 

(a)  I  s  there  a  tumor  present?  It  is  usually  easy  by  a  vaginal  ex- 
amination to  feel  the  tumor  lateral  to  or  behind  the  uterus,  or,  if  it  is  large,  to 
see  it  and  to  palpate  and  outline  it  by  percussion. 

Patients  often  mistake  tympany  for  a  tumor  and  appeal  to  the 
physician  for  a  decision,  usually  adding  to  their  complaint  the  statement  that 
the  tumor  increases  remarkably  at  times  and  goes  down  again.  Some  cases  of 
tympany  do  simulate  in  an  extraordinary  manner  the  configuration  of  an  abdo- 
men containing  a  cystic  ovarian  tumor ;  but  a  little  palpation — demonstrating 
the  uniformity  of  the  resistance  in  all  parts  of  the  abdomen,  and  a  few  percussion 
taps  over  the  tumor  bringing  out  the  note  of  resonance  all  over  its  surface — 
serves  at  once  to  dispel  the  illusion. 


25-1:  OVAEIOTOMY. 

In  the  rare  case  of  an  ovarian  tumor  which  contains  gas  and  is  therefore 
tympanitic  a  discrimination  between  this  and  intestinal  tympany  will  be  made 
by  the  fact  that  the  condition  of  the  patient  shows  that  some  grave  disease 
exists ;  an  examination  also  shows  that  the  abdominal  enlargement  is  tympanitic 
over  its  most  prominent  part,  but  flat  at  the  sides  where  the  resistant  areas  can 
be  palpated  ;  vaginal  examination  also  reveals  the  presence  of  the  firm  cyst  wall 
and  its  relations  to  the  uterus. 

The  greatest  difficulty  in  detecting  the  presence  of  a 
tumor  is  met  with  in  fat  women,  and  here  the  embarrassment  is 
twofold,  for  in  the  first  place  the  examiner  may  think  that  he  finds  a  tumor 
when  there  is  nothing  present  but  a  mass  of  fat,  and  in  the  second  place  a 
tumor  of  medium  size  may  readily  escape  observation.  The  best  rule  to  observe 
in  such  cases  is  never  to  decide  that  there  is  a  tumor  present  until  indisputable 
evidence  of  its  existence  is  secured  and  it  is  clearly  felt  by  palpation  and  outlined 
by  percussion,  and  above  all  until  its  connection  with  the  broad  ligament,  and 
so,  indirectly,  with  the  uterus,  is  made  manifest  by  a  careful  pelvic  examination, 
if  need  be,  under  anesthesia. 

It  is  always  a  good  rule  where  the  slightest  doubt 
exists  not  to  give  an  opinion  based  upon  a  single  obser- 
vation,   but   to   see   the   patient   two   or   more   times. 

It  is  equally  hazardous  when  a  woman  is  excessively  fat  to  decide  hastily  that 
there  is  no  tumor  present,  for  experience  teaches  us  that  obesity  in  no  w^ay  hin- 
ders the  growth  of  an  ovarian  cyst.  In  such  a  case  a  doubtful  ovarian  tumor 
felt  by  the  abdomen  may  be  felt  distinctly  by  the  vagina  and  by  the  rectum. 
The  clearest  evidence  that  the  patient  is  not  suffering  from  an  ovarian  tumor  is 
obtained  by  giving  an  anesthetic  and  then  examining  the  uterus  and  broad  liga- 
ments thoroughly  through  the  emptied  rectum,  and  by  palpating  and 
outlining   both   ovaries. 

When  an  ovarian  tumor  as  large  as  one  or  two  fists  has  a  long  pedicle  and 
slips  up  into  the  flank,  it  may  entirely  escape  observation,  unless  it  is  system- 
atically sought  for  in  this  position  by  palpating  both  flanks  between  the  hands, 
one  placed  in  front  and  one  behind.  This  lodgment  of  a  tumor  in  a  flank  is 
most  apt  to  occur  and  most  likely  to  escape  observation  when  there  are  two 
tumors  present  and  the  larger  one  lies  prominently  under  the  abdominal  wall, 
easy  of  access  and  diagnosis. 

(b)Is  the  tumor  ovarian?  The  differential  diagnosis  of  an  ovarian 
tumor  from  all  the  other  tumors  which  may  be  found  in  the  abdominal  cavity 
must  be  made  by  discovering  in  the  particular  case  the  presence  of  certain 
features  characteristic  of  ovarian  tumors,  as  well  as  by  noting  the  absence  of 
those  features  which  are  peculiar  to  other  kinds  of  tumors. 

The  methods  of  making  the  diagnosis  will  also  vary  according  as  the  tumor 
is  small  and  still  confined  to  the  pelvis,  or  larger,  from  the  size  of  a  child's  head 
to  that  of  a  pregnant  uterus  at  term,  or  from  the  size  of  the  uterus  at  term  up  to 
the  largest  tumors  observed. 

In  order  to  differentiate  an  ovarian  tumor  from  abdominal  tumors  of  other 


DIAGNOSIS.  255 

kinds,  therefore,  the  following  facts  must  be  borne  in  mind  in  making  the 
examination  : 

The  ovarian  tumor  is  dull  to  percussion  over  its  convexity,  and  is  surrounded 
by  an  area  of  resonance  above  and  at  the  sides ;  it  is  dull  also  below,  on  the  side 
toward  the  pelvis  ;  this  dull  area  below  points  out,  as  it  were,  its  natural  habitat, 
and  may  be  compared  to  the  trunk  of  a  tree,  showing  the  place  from  which  it 
has  its  origin. 

The  ovarian  tumor  is  attached  to  the  Inroad  ligament  by  a  pedicle  which  can 
be  felt  by  the  rectum. 

It  replaces  the  normal  ovary  of  the  side  from  which  it  springs. 

By  finding  a  normal  ovary  on  one  side  and  none  on  the  other,  but  in  its 
place  a  tumor,  the  diagnosis  is  made  certain. 

The  conclusion  is  often  easily  reached  that  a  tumor  is  pelvic  in  its  origin, 
but  the  more  exact  nature  of  the  pelvic  tumor  may  not  be  so  easy  to  determine. 
The  differential  diagnosis  must  here  be  made  between  the  ovarian  and  the  various 
uterine  and  retroperitoneal  tumors  and  an  overdistended  bladder.  I  have  seen 
a  patient  brought  a  long  distance  for  operation  where  there  was  nothing  but  a 
distended  bladder,  relieved  at  once  bypassing  a  catheter.  In  another 
case  preparations  were  made  for  operation  upon  a  parovarian  cyst  which  proved 
just  before  the  operation  to  be  nothing  but  a  distended  bladder.  There  is  some- 
thing characteristic  about  the  very  appearance  of  an  over-full  bladder  which 
forms  an  elongate  ovoid  in  the  median  line,  more  prominent  just  above  the 
symphysis  than  any  ovarian  tumor  of  like  size.  The  invariable  custom  of  pass- 
ing a  catheter  just  before  operation  will  prevent  mortifying  mistakes. 

Retroperitoneal  tumors  are  usually  firm  and  fixed  by  a  broad  base, 
and  their  nature  becomes  evident  when  the  rectum  is  found  lying  in  front  of 
the  tumor. 

Pregnancy  and  uterine  tumors  are  most  liable  to  be  confused 
with  ovarian  tumors,  but  such  mistakes  can  occur  but  rarely  if  in  every  instance 
the  examination  is  properly  conducted  through  the  inferior  strait  and  the  entire 
uterus  is  outlined  by  vaginal  or  rectal  examination,  and  if  the  rule  is  persisted  in 
of  giving  an  anesthetic  and  making  a  minute  examination  in  all  doubtful  cases. 

Tuberculosis  and  encysted  peritonitis  may  easily  be  confused 
with  an  ovarian  tumor,  but  in  both  these  conditions  the  enlargement  usually 
exhibits  some  indefiniteness  of  outline  and  peculiar  irregular  areas  of  tympany 
and  dullness,  the  mobility  is  slight,  and  the  areas  of  dullness  are  apt  to  change 
from  week  to  week.  Tubercles  may  sometimes  be  distinctly  felt  through  the 
thin  wall  of  the  rectum. 

A  large  cystic  kidney  may  extend  from  the  diaphragm  to  the  pelvic 
floor,  closely  resembling  an  ovarian  tumor,  but  the  fact  must  ever  be  l)orne  in 
mind  that  the  kidney  has  a  tympanitic  area  in  front  of  it,  due  to  the  displaced 
colon. 

A  small  ovarian  tumor  must  be  differentiated  from  small  uterine 
tumors,  tul)al  tumors,  and  fecal  masses.  The  ovarian  tumor  possesses  these 
characteristics :  it  lies  to  one  side  of  or  behind  the  uterus,  it  is  usually  e%'idently 


256  OVARIOTOMY. 

cjstic  from  the  more  or  less  distinct  sense  of  fluctuation,  and  is  always  movable 
as  distinct  from  the  uterus,  with  which  its  connection  may  often  be  traced  by 
the  utero-ovarian  ligament  on  one  side.  By  recognizing  these  peculiarities  in 
any  given  case  the  possibiHty  of  the  tumor  being  uterine  is  excluded.  The 
greatest  diflficulty  is  met  with  when  the  small  ovarian  tumor  is  adherent  to  the 
uterus ;  the  tumor  is  then  usually  lateral  to  the  uterus,  it  is  fluctuant,  and,  in 
addition,  the  firm  uterine  body  can  be  outlined  independent  of  the  tumor;  a 
careful  palpation  also  shows  a  slight  independent  mobility. 

A  tubal  tumor  is  thin-walled,  elongate,  sausage-shaped,  and  often  con- 
voluted, and  in  addition  the  normal  ovary  may  be  felt  close  by. 

Fecal  masses,  although  liable  to  confuse  at  the  first  examination,  will 
not  do  so  when  the  bowels  have  been  thoroughly  evacuated  and  a  high 
rectal    examination    is    made. 

Ovarian  tumors  of  medium  size,  from  that  of  a  child's  head  to 
a  uterus  at  term,  may  best  be  differentiated,  first,  by  outlining  the  other  abdomi- 
nal and  pelvic  organs  by  palpation  and  percussion,  and  so  excluding  their  par- 
ticipation, and  then  by  grasping  the  cervix  with  a  tenaculum  forceps  and  pulling 
it  down,  by  which  means  perceptible  traction  is  made  upon  the  tumor ;  or  by 
grasping  the  cervix  and  pulling  it  down  and  then  pulling  the  tumor  up  in  the 
abdomen,  when  the  hand  holding  the  forceps  is  seen  to  respond  to  the  traction. 

If  a  rectal  examination  is  made  at  this  time  the  tense  pedicle  may  be  felt, 
showing  on  which  side  the  tumor  arises. 

Ovarian  tumors  filling  the  abdomen  need  to  be  distinguished 
from  all  other  large  abdominal  tumors,  and  here  the  diflficulties  are  greater, 
because  the  surrounding  area  of  tympany  is  not  always  easily  outlined,  and  the 
tumor  has  no  free  space  left  in  which  it  can  be  moved  about ;  it  is  impossible 
also  either  to  demonstrate  the  existence  of  a  pedicle  or  its  position. 

The  following  points  will  usually  be  decisive  in  such  cases  : 

There  is  a  vast  dull  area  over  the  tumor  and  at  the  sides  and  extending 
down  into  the  pelvis,  but  by  taking  particular  pains,  tympany  may  be  found  far 
back  in  the  flanks  and  up  under  the  ribs.  The  vaginal  examination  further 
shows  that  the  uterus  is  displaced  and  the  pelvis  is  choked  by  the  tumor. 

The  surface  of  the  tumor  may  present  characteristic  bosses,  with  evident 
fluctuation  at  points ;  the  uterus  is  intact  and  displaced,  crowded  down  onto  the 
pelvic  floor,  or  elevated  out  of  the  pelvis  in  front  of  the  tumor,  where  it  may 
often  be  felt  above  the  symphysis. 

Ascites  is  sometimes  taken  for  an  ovarian  tumor,  and  a 
mistake  is  often  made  when,  with  the  ascites,  cystic  tumors  exist  in  the  pelvis. 
If  the  woman  has  borne  children  or  has  relaxed  abdominal  walls,  a  form  of  abdo- 
men may  be  developed  which  is  almost  peculiar  to  ascites ;  as  the  patient  lies  on 
her  back  the  walls  belly  out  at  the  sides  and  the  top  is  flattened,  like  a  bladder 
half  full  of  water ;  this  appearance  is  rarely  simulated  by  a  flaccid  parovarian 
cyst. 

The  area  of  dullness  and  tympany  in  ascites  is  one  of  its  most  important 
characteristics ;  the  intestines  float  in  the  fluid  and  yield  a  tympanitic  note  over 


DIAGNOSIS.  257 

the  highest  point,  while  the  fluid  gravitates  downward,  giving  a  dull  note  in 
whatever  position  the  patient  is  placed.  This  valuable  sign  is  wanting  under 
two  conditions :  When  there  is  a  small  amount  of  ascitic  fluid  and  the  colon  is 
distended  with  gas,  we  may  find  tympany  in  the  flanks  ;  and,  on  the  other  hand, 
when  the  abdomen  contains  so  much  fluid  that  the  anterior  abdominal  wall  is 
pushed  out  so  that  the  intestines  held  back  by  the  mesentery  can  not  reach  it, 
the  tympanic  note  is  wanting  above.  In  the  first  case  a  mistake  will  be  avoided 
if  careful  attention  is  given  to  the  peculiar  sense  of  free  fluid  conveyed  upon 
palpation,  and  if  the  changes  in  the  areas  of  dullness  upon  change  of  position  of 
the  patient  are  also  noted.  When  a  large  ascitic  accumulation  is  present  a  mis- 
take may  still  be  made,  even  after  careful  study  of  the  case,  especially  when  the 
patient  is  so  ill  that  a  thorough  examination  is  impossible. 

I  made  such  an  erroneous  diagnosis  in  the  case  of  a  colored  woman,  who  was 
so  feeble  that  she  could  not  lie  down,  and  a  vaginal  examination  had  to  be 
omitted.  On  tapping,  what  appeared  to  be  a  straw-colored  ascitic  fluid  escaped 
and  the  abdomen  collapsed ;  no  trace  of  a  tumor  could  be  felt  (see  Fig.  405). 
She  died  later  of  exhaustion,  and  a  multilocular  ovarian  cyst  was  found  with  one 
enormous  sac  in  front  of  it.  When  the  ascites  is  due  to  a  pelvic  tumor  this  will 
be  felt  jper  vaginaTn^  while  the  ascites  gives  the  usual  signs  at  the  abdominal 
examination. 

In  order  to  get  rid  of  the  unsatisfactory  regional  terms  in  common  use  in 
our  descriptions,  I  have  for  the  past  six  years  in  my  teaching  designated  ab- 
dominal tumors  as  follows  :  Those  descending  into  the  cavity  from  beneath  the 
ribs  I  call  anatropic  ;  those  ascending  from  the  pelvis,  orthotropic; 
and  those  pushing  out  into  the  abdomen  from  the  flanks  as  amphitropic, 
borrowing  the  tenns  from  the  botanic  description  of  the  ovule  ;  those  which  are 
in  the  middle  of  the  abdomen,  surrounded  by  an  area  of  resonance  on  all  sides, 
may  be  designated  m  e  s  o  t  r  o  p  i  c . 

Right  or  left  orthotropic,  amphitropic,  or  anatropic  serve  further  to  desig- 
nate tumors  in  the  right  or  left  iliac  fossae,  the  right  or  left  loin,  or  coming 
from  under  the  right  or  left  ribs. 

(c)  What  kind  of  an  ovarian  tumor  is  present  may  some- 
times be  a  difiicult  question  to  answer. 

In  general,  the  cystic  tumors  can  be  easily  separated  from  the  solid  ones  by 
the  marked  difference  in  the  resistance,  the  smaller  size  of  the  solid  growths, 
and  their  frequent  association  with  ascites. 

Among  the  cystic  tumors  we  have  to  distinguish  the  adeno-cystomata 
(the  common  multilocular  ovarian  cysts),  cystic  papillomata,  dermoid  cysts,  paro- 
varian cysts,  cysto-carcinomata,  and  cysto-sarcomata. 

A  multilocular  cyst  may  sometimes  be  distinguished  by  the  eye  alone,  espe- 
cially when  it  consists  of  a  number  of  cysts  with  well-defined  depressions  be- 
tween them,  and  when  the  abdominal  walls  are  thin  enough  to  reveal  the  con- 
tour of  tlie  growth. 

The  chief  difficulty  in  differentiating  a  polycyst  is  its  tendency  to  form  one 
large  cyst  which,  owing  to  its  spherical  form,  rotates  and  adapts  itself  to  the 
58 


258  OVARIOTOMY. 

concavity  of  the  anterior  abdominal  walls,  and  so,  to  palpation,  closely  resembles 
a  unilocular  parovarian  cyst.  The  distinction  may  often  be  made  by  observing 
that  the  wall  of  a  polycyst  appears  thick  on  palpation  and  its  contents  seem  to 
be  of  more  than  watery  consistence ;  if  a  careful  search  is  made  in  the  flanks, 
irreo-ular  bosses  may  be  felt  there  or  high  up  under  the  ribs ;  sometimes  a  large 
cyst  fills  the  abdomen,  and  a  careful  palpation  by  the  pelvis  reveals  tlie  presence 
of  a  conglomeration  of  cysts  budding  off  in  this  direction  from  the  main  cyst 
above.  Where  the  furrows  between  the  separate  cysts  can  not  be  distinctly 
made  out,  a  marked  difference  in  the  tension  between  two  or 
more  cysts  may  be  discovered  by  palpation  of  the  tumor  in  all  pos- 
sible directions. 

The  fact  that  a  large  abdominal  tumor  fills  the  pelvis  also  and  possesses  an 
irregular  form  does  not  prove  that  it  is  polycystic,  for  these  characteristics  may 
be  observed  in  parovarian  cysts. 

Papillomata  can  not  be  diagnosticated  when  the  outgrowths  are  confined  to 
the  interior  of  cystic  tumors.  Small  superficial  papillomata  may,  however,  some- 
times be  recognized  as  excrescences  plainly  felt  by  the  vagina  or  rectum,  and 
the  association  of  ascites  with  a  small  tumor  which  is  often  fixed  in  the  pelvis,  in 
the  absence  of  any  grave  constitutional  disturbances,  should  arouse  the  suspicion 
of  papillomata.  When  the  disease  is  more  extensive,  the  pelvis  choked,  and  im- 
plantation masses  with  much  ascites  are  found  on  the  abdominal  walls  and  in  the 
omentum,  the  diagnosis  may  be  made  without  difiiculty,  particularly  after  tap- 
ping, when  the  contents  are  much  more  plainly  palpable. 

In  making  a  differential  diagnosis  between  dermoids  and  other  tumors  these 
facts  must  be  borne  in  mind.  Kiister  has  shown  that  the  dermoid  cyst  tends  to 
float  up  in  front  of  the  uterus  ;  it  is  also  a  tumor  of  slow  growth,  oftenest  found 
in  children  and  young  women,  and  is  frequently  painful. 

The  dermoid  is  usually  monocystic,  single,  not  often  larger  than  a  man's  head, 
and  the  fluid  fat,  on  palpation,  feels  like  water  or  of  the  consistency  of  mush. 

Parovarian  cysts  convey  the  impression,  both  by  the  touch  and  by  the  uni- 
formity of  the  abdominal  enlargement,  that  they  are  unilocular  and  thin -walled, 
and  although  they  may  have  well-deflned  pedicles,  usually  they  fill  out  the  meso- 
salpinx at  least,  and  so  have  a  broad  base  of  origin. 

Cysto-carciuomata  and  cysto-sarcomata  convey  the  impression  of  unilocular 
cysts  often  with  thick  resilient  walls  ;  in  their  earliest  stages  they  present  no 
characteristic  features,  but  later  there  is  ascites,  emaciation,  and  cachexia,  and,  it 
may  be,  metastases. 

Among  the  hard  tumors  we  have  to  distinguish  the  solid  carcinomata, 
the  fibromata,  and  some  sarcomata. 

The  fibroid  is  usually  a  dense  tumor  accompanied  by  ascites  and  unaccompanied 
by  any  serious  constitutional  depression,  in  marked  contrast  to  the  loss  of  appe- 
tite and  strength,  the  emaciation,  cachexia,  and  edema  of  the  malignant  growths. 

The  carcinoma  often  involves  both  ovaries,  is  hard  and  nodular,  and  is  found 
in  much  younger  patients  than  the  fibroma ;  metastases  are,  of  course,  pathog- 
nomonic. 


Fig.  406. — Typical  Polycystic  Ovarian  Tumok,  with  Long  Twisted  Pedicle. 

The  larger  portion  of  the  ovary  ( Ov)  is  intact,  and  the  tumor  occupies  its  outer  extremity.    The  abdominal 
end  of  the  uterine  tube  lies  below  the  ovary.    Jan.  2.3,  1897.    }4  natural  size. 


MULTILOCULAR    OVARIAN    CYST-ADENOMA.  259 

Multilocular  Ovarian  Cyst-adenoma. — The  multilocular  ovarian  cyst-adenoma  is 
the  classical  tumor  of  the  gynecologist,  recognized  and  operated  upon  for  many 
years  before  any  clear  distinctions  as  to  the  microscopical  or  clinical  characters 
of  other  ovarian  tumors  obtained  recognition  (see  Fig.  406). 

Pathology . — The  ovarian  cyst-adenoma  owes  its  origin  to  a  multiplica- 
tion of  the  glandular  elements  of  the  ovary  ;  these  glands  become  distended 
with  secretion,  the  fluid  accumulating  with  varying  degrees  of  rapidity  to  form 
cysts  of  all  sizes.  The  cysts  are  usually  unilateral,  occurring  somewhat  more 
often  on  the  right  side  than  on  the  left,  but  they  may  occur  in  both  ovaries  at 
the  same  time  ;  six  per  cent  of  my  cases  have  been  double. 

They  vary  greatly  in  size,  some  being  not  larger  than  an  orange,  while 
others  appear  as  huge  masses  weighing  upward  of  one  hundred  pounds ;  such 
large  tumors,  however,  are  rarely  met  with  any  longer,  because  the  patient  pre- 
sents herself  for  treatment  before  the  cyst  can  reach  such  a  size  and  cause  much 
discomfort. 

The  entire  tumor  usually  lies  free  in  the  abdominal  cavity  and  appears  as  a 
round  or  oval  mass,  with  a  smooth  and  glistening  surface,  irregular  in  outline, 
presenting  many  large  or  small  bosses.  These  bosses  represent  the  individual 
cysts,  whose  walls  are  pearly  white  or  slightly  bluish  or  pinkish  in  color ;  be- 
neath the  peritoneum  numerous  branching  blood  vessels  can  be  seen  radiating 
out  from  the  main  trunks  at  the  pedicle.  On  section,  the  appearance  usually 
seen  is  that  of  one  or  more  large  cysts  surrounded  by  numerous  small  ones, 
many  of  the  smaller  ones  being  situated  in  the  walls  of  the  larger  ones,  for  as 
the  cysts  enlarge  their  walls  come  in  contact,  and  when  by  the  increasing  pres- 
sure the  partitions  between  them  are  so  thinned  as  to  rapture,  the  adjoining  cysts 
unite  (see  Fig.  407).  In  a  recent  rupture  the  remainder  of  the  septum  is  seen 
as  a  perforated  diaphragm,  later  it  forms  a  falciform  edge  on  the  cyst  wall,  and 
still  later  appears  simply  as  a  ridge  or  band.  More  rarely  the  greater  portion  of 
the  tumor  is  formed  of  masses  of  small  cysts,  which,  on  section,  give  a  honey- 
combed appearance  to  the  cut  surface. 

The  cyst  walls  vary  from  4  to  5  milHmeters  in  thickness.  They  are  com- 
posed of  a  dense  tissue,  which  here  and  there  may  contain  areas  of  calcification 
and  occasionally  a  dilated  Graafian  follicle,  or  a  corpus  luteum  can  be  demon- 
strated in  a  thickened  portion  of  the  wall,  or  irregular,  brown,  slightly  raised 
patches  may  be  seen  which  represent  the  site  of  old  hemorrhages. 

The  cysts  are  separated  from  one  another  by  delicate  partitions,  and  have 
smooth,  glistening  inner  surfaces  which  are  of  a  bluish  or  pinkish  hue.  Fre- 
quently in  the  largest  cysts  trabeculne  will  be  seen  extending  from  one  side  of 
the  cyst  wall  to  the  other ;  these  are  the  remains  of  old  cyst  walls.  On  histo- 
logical examination,  the  surface  of  the  tumor  may  show  no  epithelial  covering,  or 
may  be  covered  by  one  layer  of  flat  cells.  The  cyst  walls  are  composed  of  con- 
nective tissue  which  is  arranged  in  layers  parallel  to  the  outer  surface,  and  near 
the  inner  surface  the  tissue  is  rich  in  cell  elements.  The  blood  supply  varies 
greatly,  being  sometimes  abundant  and  at  other  times  scanty.  There  is  fre- 
quently hemorrhage  into  the  cyst  wall,  the  brown  patches  seen  on  the  inner  sur- 


260  OVARIOTOMY. 

face  being  the  sites  of  old  hemorrhages  which  have  been  invaded  by  connective- 
tissue  cells  from  the  cyst  wall,  and  over  which  the  epithelium  is  wanting.  The 
cyst  walls  are  also  often  edematous  and  may  be  necrotic  in  places.  Occasionally 
such  ovarian  elements  as  Graafian  follicles,  corpora  lutea,  and  corpora  fibrosa  are 
found  scattered  throughout  the  walls.  In  the  vicinity  of  the  pedicle  non-striped 
muscle  fibers  may  sometimes  be  demonstrated. 

The  partitions  between  the  smaller  cysts  are  also  composed  of  connective  tis- 
sue richer  in  cell  elements  than  that  which  forms  the  outer  cyst  wall,  and  in  this 
tissue  numerous  convoluted  glands  are  seen  which  are  the  rudimentary  cysts. 

The  inner  surfaces  of  both  the  small  and  large  cysts  are  lined  by  a  single 
layer  of  cylindrical  epithelium  which  is  often  ciliated.  The  nuclei  of  these 
cells  are  oval  or  almost  flat,  and  are  usually  situated  immediately  on  the  base- 
ment membrane.  Some  of  the  cells  are  swollen  and  filled  with  clear  contents, 
resembling  goblet  cells,  and  nuclear  figures  are  also  occasionally  seen.  In  some 
of  the  larger  cysts,  but  more  especially  in  the  smaller  ones,  the  walls  present  a 
scalloped  or  convoluted  appearance  resembling  acinous  glands. 

Calcified  areas  are  common,  appearing  either  as  small  scales  in  the  fibrous 
tissue  of  the  walls,  or  as  little  granules,  which  are  usually  calcified  epithehal 
cells. 

An  ovarian  cyst  is  not  infrequently  associated  with  a  dermoid  cyst  of  the 
opposite  side  or  a  parovarian  cyst  (see  Fig.  408). 

Contained  Fluid . — The  fiuid  in  the  larger  cysts  is  thinner  than  that  in 
the  smaller  ones.  It  may  be  grayish  yellow,  gray,  reddish  brown,  or  dark  brown 
in  color,  the  coloring  depending  to  a  great  extent  on  the  hemorrhages  which 
have  taken  place  in  the  cyst  cavity ;  the  blood  is  usually  distributed  equally 
through  the  cyst  fluid,  and  clots  are  rarely  found. 

The  specific  gravity  of  the  fluid  varies  from  1010  to  1030.  It  contains  much 
albumin,  and  the  microscopical  examination  reveals  'desquamated  fatty  epithe- 
lium, and  also  large  cells  which  are  filled  with  yellowish  pigment  and  which 
probably  have  the  same  origin.  Some  of  the  smaller  cysts  contain  a  yellowish- 
white,  semi-transparent  viscid  fluid ;  others  a  yellowish  transparent,  jellylike 
material,  which  is  but  slightly  tenacious.  The  fluid  from  the  smaller  cysts,  as 
in  the  larger  ones,  contains  desquamated  epithelium,  fat  droplets,  and  detritus. 
Occasionally  a  few  needle-shaped  crystals  are  seen  scattered  through  the  fluid. 

The  fluid  which  is  present  in  these  cysts  has  three  sources  of  origin  :  the 
secretion  from  the  epithelial  cells,  the  transudation  of  serum  from  the  blood 
vessels,  and  the  destruction  of  cells. 

P  s  e  u  d  o  m  u  c  i  n . — Pseudomucin  is  one  of  the  most  important  of  the  con- 
stituents of  the  glandular  ovarian  cystomata,  and  is  almost  characteristic. 

In  the  days  when  ovariotomy  was  exceedingly  dangerous  great  importance 
was  attached  to  the  microscopic  and  the  chemical  examination  of  portions  of  the 
cyst  fluid  removed  for  diagnostic  purposes,  and  the  discovery  in  this  way  of  the 
"ovarian  cell,"  the  "compound  granular  cell,"  and  of  paralbumin  and  metal- 
bumin  (Scherer),  were  looked  upon  as  decisive  in  determining  the  presence  of 
an  ovarian  cyst. 


.% 


■ft 


T> 


Fig.  407 . — Multilocular  Ovarian  Cyst,  ix  which  the  Smaller  Cysts  project  into  the  Cavity  of  the 
Large  (Jne,  which  in  this  Way  presents  Externally  the  Appearance  of  a  Monocystic  Tumor. 

The  utero-ovarian  ligament  and  the  uterine  tube  are  seen  cut  across  below.    No.  880.    %  natural  size. 


MULTILOCULAK    OVARIAX    CYST-ADENOMA. 


261 


The  "  ovarian  cell "  has  long  since  disappeared,  but  paralbumin  and  metalbu- 
min  have  kept  their  place  with  an  identity  which  has  been  altered  by  O.  Hammar- 
stein  {Ein  Beitr.  z.  Chemie  d.  Kystorri  Flussigkeiten.  Zeits.  f.  Phys.  CJiein.^ 
1882),  who  has  shown  that  they  do  not  belong  to  the  albumin  group,  as  at  first 
supposed.  While  paralbumin  is  not  a  chemically  pure  body,  metalbumin,  on 
the  other  hand,  is  closely  allied  to  mucin,  and  to  avoid  confusion  he  has  given 
it  the  name  "  p  s  e  u  d  o  m  ii  c  i  n ." 

Chemical  examination  of  metalbumin — that  is  to  say,  pseudomucin — showed 
that  its  chief  characteristic  was  a  liabiUty  upon  boiling  with  acids  to  separate  a 


Ji.  Sec.<e  -y^<: 
Fig.  408. — Polycystic  Ovarian  Tcmor  and  Parovarian  Cyst  existing  on  the  Same  Side. 
Between  the  cysts  is  a  firm  nodule  about  the  size  of  a  bean.    Dec.  19, 1896.    Natural  size. 

carbohydrate  ;  it  differs  from  mucin  in  its  reaction  with  acetic  acid.  Pfannen- 
stiel,  in  a  most  careful  study  of  this  substance  in  its  relation  to  ovarian  cysts 
(Arch./.  Gyn.,  Bd.  xxxviii,  1890,  p.  407),  applies  to  it  the  term  "  glycoproteid," 
because  it  splits  up  into  an  albumin  and  a  sugar. 

Pseudomucin  is  particularly  abundant  in  cysts  containing  the  tough,  sticky, 
mucilaginous  substance  often  capable  of  being  drawn  out  in  long  threads  ;  as  it 
is  soluble  in  water,  its  presence  in  small  quantities  can  only  be  recognized  by 
chemical  tests, -of  which  the  folloNving  is  one  of  the  simplest  practicable  (see 
E.  Salkowski,  Practicum  der  physiologisehen  und  jpathologischen  Chemie^  1893» 
S.  174) : 


262 


OVAKIOTOMT. 


To  25  centimeters  of  the  cyst  fluid  add  75  centimeters  of  95  per  cent  alcohol. 
Sliake,  filter,  and  wash  the  residue  well  mth  alcohol.  Then  press  out  the  resi- 
due between  blotting  paper  to  free  it  from  the  alcohol.     ISText  boil  the  residue 

in  a  solution  of  hydrochlo- 
ric acid  and  water  (acid  1 
pint,  water  3  pints).  Neu- 
ti'alize  the  solution  with  so- 
dium hydrate  (15  per  cent 
solution).  Then,  if  a  fresh- 
ly made  Fehling's  solution 
precipitates  the  copper  ox- 
ide, this  shows  the  presence 
of  the  carbohydrate  in  the 
cyst  fluid,  and  hence  of 
pseudomucin. 

It  is  also  to  Pfannen- 
stiel's  credit  that  he  has 
shown  that  pseudomucin 
does  not  result  from  a  col- 
loid degeneration  of  the 
cells,  as  supposed,  but  that 
it  is  a  real  secretion  of  the 
epithelial  cells,  which  goes 
on  indefinitely  without  cell 
destruction. 

The  various  stages 
through  which  the  cells 
pass  in  the  formation  and 
excretion  of  pseudomucin 
may  be  beautifully  seen  in 


Fig.  409. — Multiple  Adeno-cystomata  of  the  Ovary. 

Showino:  the  ten.acious  character  of  the  pseudomucinous  contents 
of  the  small  cysts  discharging  on  the  inner  surface  of  a  larger  one. 
The  two  openings  seen  are  not  artificial. 


a  single  cyst.  The  original 
epithelial  cells  lining  the  cyst  walls  are  short  cylinders  with  a  nucleus  at  the  base, 
and  a  feebly  staining  protoplasm  (albumin) ;  then  we  find  long  cells  with  a  basal 
nucleus  and  a  still  more  feebly  staining  cell  body,  the  first  step  in  the  evolution 
of  pseudomucin,  which  at  this  stage  is  evenly  distributed  throughout  the  cell 
body  and  gives  it  already  a  somewhat  glassy  appearance.  The  next  step  is  the 
separation  of  the  pseudomucin  from  the  protoplasm,  the  pseudonmcin  lying  in 
the  periphery,  while  the  protoplasm  is  crowded  down  to  the  base  of  the  cell,  the 
proportion  between  the  two  varying  with  the  amount  of  pseudomucin  excreted ; 
some  cells  appear  to  be  entirely  filled  with  the  pseudomucin.  These  various 
stages  are  all  illustrated  in  Fig.  410. 

Pseudomucin  is  never  found  in  normal  ovaries,  dropsical  Graafian  follicles,  or 
in  parov^arian  cysts ;  it  is  found  in  some  forms  of  papillary  cysts,  and  is,  as  stated, 
the  constant  characteristic  element  in  the  classical  glandular  ovarian  tumors  ;  it 
only  occurs  in  ascitic  fluids  in  the  presence  of  a  tumor  also  containing  pseudomucin. 


MULTILOCULAR   OVARIAN"    CYST-ADENOMA. 


203 


Development . — The  cysts  usually  develop  and  lie  free  in  the  abdominal 
cavity,  with  a  well-marked  pedicle  formed  by  the  ovarian  ligament,  the  uterine 
tube,  and  the  broad  ligament ;  and  if  the  tumor  is  large  and  exerts  much  trac- 
tion, this  pedicle  will  be  several  inches  long.  The  parovarian  is  in  most 
cases  intact. 

Occasionally  the  development  is  between  the  layers  of  the  broad  ligament, 
when  they  are  called  intraligamentary  cysts ;  they  may  then  push  toward  the  ute- 
rus, toward  the  bladder, 
backward  into  Doug- 
las's cul-de-sac,  and  be- 
tween the  layers  of  the 
peritoneum  under  the 
cecum  and  the  rectum. 

Adhesions  between 
the  abdominal  viscera 
and  some  portion  of  the 
cyst  are  present  in  a 
certain  proportion  of 
the  cases;  thus,  among 
thirty  -  six  multilocular 
cysts  which  I  have  op- 
erated upon,  twenty- 
two  of  them  presented 
no  adhesions  at  all, 
while  fourteen  were  ad- 
herent in  varying  de- 
grees from  a  few  light 
omental  attachments  all 
the  way  to  extensive 
parietal,  intestinal,  and 
pelvic  adhesions. 

The  omentum  is 
more  apt  to  contract 
adhesions  with  the  cyst 
wall  than  any  other 
abdominal  organ,  and 
these  adhesions  may  be 
in  the  form  of  one  or  more  long  ribbons  attached  to  the  tumor  at  the  lower 
end,  or  the  whole  free  border  of  the  omentum  may  be  adherent. 

Formerly,  when  tapping  was  resorted  to,  adhesions  were  found  quite  uni- 
formly between  the  abdominal  painetes  and  the  cyst  wall  at  the  point  of  puncture. 
Where  the  cyst  walls  are  thin  and  the  accunuilation  of  fluid  rapid,  the  wall  of 
the  largest  cyst  may  rupture,  allowing  the  contents  to  escape  into  the  abdomi- 
nal cavity.  Where  this  occurs,  the  smaller  cysts  develop  rapidly,  project  into 
the  rent  produced  in  the  large  cyst,  and  eventually  completely  obliterate  it. 


j^^scJi-exyei: 


Fig.  410. — The  Wall  of  a  Multilocular  Ovarian"  Cyst  magnified 
170  Times,  showing  the  Secreting  Glandular  Spaces  and  the 
Method  of  Formation  of  Pseudomucin. 

In  the  larffe  space  on  the  right  the  lininij  epithelial  cells  are  seen  in 
various  staires,  from  those  whicli  are  markedly  granular  and  contain  uo 
pseudomucin,  to  those  in  which  the  cell  contents  are  lighter;  and,  tiually, 
those  in  which  a  goblet  cell  has  been  formed  full  of  pseudomucin,  and 
even  bursting  into  the  cyst.    Spec.  538. 


264  OVARIOTOMY. 

The  escape  of  fluid  into  the  abdomen  may  be  followed  by  a  condition  called 
pseudo-my xomatous  peritonitis. 

The  growth  of  these  cysts  is  usually  rapid — in  general  more  rapid  than  that 
of  the  parovarian  cysts,  although  the  initial  stages  are  never  noted  ;  thus,  out 
of  thirty-five  cases,  the  growth  is  noted  as  rapid  in  twenty-three,  gradual  in 
seven,  and  slow  in  but  five,  and  out  of  these  five  two  had  ruptured  and  decreased 
in  size  and  then  reappeared.  The  longest  duration  noted  among  my  cases  was 
ten  years ;  others  were  known  to  have  existed  for  five  years,  three  years,  one 
year  and  a  half,  one  year,  six  months,  two  months,  and  five  weeks. 

Cause . — The  causation  is  quite  unknown,  though  age  is  clearly  a  strongly 
predisposing  factor,  since  they  are  rarely  found  in  girlhood  or  in  old  age. 

My  youngest  patient  was  fifteen  years  old,  and  my  two  oldest  seventy-three 
and  seventy-five.  The  average  age  of  all  my  cases  was  forty-two  years  and 
six  months ;  this  shows  the  period  of  strongest  predisposition  lies  near  the  close 
of  the  reproductive  period. 

The  proportion  of  married  to  single  women  was  as  3  to  1  in  thirty-four  cases, 
and  the  married  women  averaged  two  children  each.  There  is  no  I'eason  for 
believing  that  childbirth  has  anything  to  do  with  causation. 

These  tumors  are  usually  discovered  only  after  they  have  become  large 
enough  to  produce  a  noticeable  distention  of  the  abdomen,  and  there  is  a  form 
of  abdomen  which  is  characteristic  of  the  large  ovarian  cysts  ;  the  distention  is 
chiefly  in  the  lower  abdomen,  where  the  walls  are  splinted  over  the  tense  sac, 
though  the  rise  from  the  pubes  up  to  the  point  of  greatest  prominence  is  not  so 
abrupt  as  in  the  large  spherical  myomata.  Above  this  the  walls  rise  and  fall 
with  respiration,  as  shown  in  Yol.  I,  Ch.  Y,  PI.  II. 

If  the  cyst  is  large  the  flanks  are  filled  out,  but  they  do  not  sag  as  in  an 
ascites.  The  general  flattened  cylindrical  enlargement  of  the  abdomen  seen  in 
ascites  is  wanting. 

When  the  tumor  grows  large  enough  the  abdominal  wall  below  the  umbili- 
cus yields,  and  the  mass  falls  forward  in  fi*ont  of  the  thighs,  or  even  as  low 
down  as  the  knees. 

One  of  my  patients  had  an  ovarian  tumor  of  this  kind,  weighing  one  hundred 
and  sixteen  pounds,  and  had  not  seen  her  feet  or  knees  for  months.  Another 
patient  had  a  large  ovarian  cyst  added  to  her  natural  stoutness.  (See  also  Yol. 
I,  p.  83,  Fig.  52.) 

The  average  girth  of  these  large  tumors,  as  illustrated  by  measuring  six  pa- 
tients with  large  ovarian  cysts,  was  108  centimeters  (43*2  inches),  the  largest 
measurement  being  123  centimeters  (■19-2  inches) ;  when  the  circumference  ex- 
ceeds 100  centimeters  (40  inches)  the  measurement  does  not  indicate  exactly  the 
size  of  the  tumor,  as  the  subsequent  distention  is  apt  to  take  place  downward. 

Symptoms . — Pressure  symptoms  are  always  produced  by  the  growing 
tumor  sooner  or  later.  Whether  they  appear  early  or  not  depends  on  the  form, 
consistence,  and  attachments  of  the  tumor.  It  is  remarkable  that  in  many  cases 
large  tumors  are  carried  "without  any  greater  inconvenience  than  the  weight. 
In  other  cases  pressure  on  the  bladder  and  rectum  interferes  with  their  func- 


Fig.  411. — Papillomata  of  Both  Ovaries,  seen  in  situ  from  behind. 

On  the  left  side  a  series  of  mulberry  masses  are  seen  hanging  from  a  delicate  pedicle  attached  to  the  Fallopian  tube;  on  the 
jht  the  ovary  is  transformed  into  a  mulberry  mass,  and  inside  a  cyst  two  masses  are  seen  sprouting.     No.  595.     Natural  size. 


PAPILLARY  TUMORS  OF  THE  OVARY.  265 

tions,  and  by  pressure  on  one  or  both  ureters,  bydroureter  and  bydronephrosis 
are  produced ;  albumin  and  easts  with  dysuria  were  noted  in  50  per  cent  of 
my  cases.     These  often  disappear  within  a  short  time  after  the  operation. 

In  the  large  tumors  there  is  often  marked  interference  with  digestion,  accom- 
panied by  flatulence,  nausea,  and  vomiting. 

The  respiratory  and  circulatory  functions  are  interfered  with  by  the  viscera 
crowded  up  under  the  diaphragm.  Other  evidences  of  pressure  are  the  edema 
of  the  legs,  lower  abdomen,  and  vulva,  and  the  development  of  the  superficial 
abdominal  veins.  The  distention  of  the  abdomen  also  produces  the  red  striae 
physiologically  found  in  pregnancy. 

Menstruation  was  not  affected  in  50  per  cent  of  my  cases ;  in  the  others  it 
was  irregular,  scanty,  or  even  absent,  or,  on  the  other  hand,  excessive. 

The  general  health  suffers  greatly ;  in  an  advanced  stage  the  patient  is  often 
extremely  emaciated.  In  only  six  of  my  cases  was  the  general  health  good.  The 
expression,  characteristic  of  the  extreme  emaciation  found  in  patients  with 
ovarian  tumors,  has  been  called  the  facies  ovariana. 

Pain  is  not  a  characteristic  symptom.  The  discomfort  produced  by  the  pres- 
sure of  the  large  cyst  upon  the  neighboring  structures,  and  usually  described  as 
a  dull,  heavy,  dragging  sensation,  was  noted  in  nineteen  of  my  cases ;  three 
spoke  of  a  sharp,  cutting  pain,  and  in  the  remainder  no  constant  pain  was  com- 
plained of.  Many  women  have  attacks  of  pain  at  longer  or  shorter  intervals, 
sometimes  severe  and  associated  with  a  slight  rise  of  temperature  and  a  quick- 
ened pulse  due  to  a  localized  peritonitis. 

These  attacks  usually  pass  off  in  a  few  days  or  a  week,  leaving  behind  them 
more  or  less  extensive  adhesions  between  the  cyst  and  adjacent  peritoneal 
surfaces. 

Papillary  Tumors  of  the  Ovary. — Papillary  tumors  of  the  ovary  consti- 
tute a  well-defined  group  peculiar  in  their  clinical  and  microscopical  aspects. 
They  are  formed  by  a  proliferation  of  the  germinal  epithelium,  either  on  the 
surface  of  the  ovary  or  in  the  Graafian  follicles  or  both. 

Papillomata  were  at  first  classified  by  Waldeyer  as  a  variety  of  the  ordinary 
ovarian  glandular  cystomata  {Archivf.  Gyn.,  Bd.  i,  1870,  p.  259).  He  explained 
the  difference  between  the  clinical  appearances  furnished  by  the  two  classes  of 
tumors  by  stating  that  in  a  cystoma  the  stimulus  of  growth  fell  upon  the  epi- 
thelial elements,  which  therefore  preponderated,  while  in  a  papilloma  the  vascu- 
lar connective-tissue  stroma  grew  more  abundantly,  and  so  pushing  out  from  its 
bed  and  covered  by  epithelium,  formed  the  characteristic  papillary  trees. 

But  Olshausen,  in  1877,  drew  a  sharp  line  of  differentiation  between  the 
papillomatous  and  the  glandular  adenomata  as  totally  different  one  fi-om  the 
other  {Die  KrankheiUn  der  Ovarien,  pp.  50-60).  Since  this  time  the  careful 
clinical  and  histological  studies  of  cases  by  numerous  observers,  and  latterly  es- 
pecially by  Dr.  J.  W.  Williams  {Johns  Hopkins  Reports^  vol,  iii,  1892)  and  by  J. 
Pfannenstiel  {Arch.f.  Gyn.,  1895,  p.  507),  have  not  only  served  to  establish  the 
dicta  of  Olshausen  but  even  to  subdivide  the  generic  papilloma  into  its  several 
well-defined  species,   of  which   the  following  foruis   are   found  :    Cystoma 


266  OVAKIOTOMY. 

parovarii  papillare;  hydrops  folliciili  Graafian!  papillaris; 
adenoma  papillare  pseudomncinosum;  adenoma  papillare 
simplex;  a  d  e  n  o  -  c  a  r  c  i  n  o  m  a  papillare;  a  d  e  n  o  -  s  a  r  c  o  m  a  pap- 
illare. 

Out  of  138  ovarian  tumors  of  all  kinds  operated  upon  and  examined  in  my 
own  clinic,  30  were  papillomata,  and  these  were  grouped  as  follows  : 

Multilocular  adeno-papillo-cystoma  (one  mixed  with  sarcoma) 15 

Solid  papillomata 9 

Solid  papillo-adeno-carcinoma 1 

Cystic  papillo-adeno-carcinoma 2 

Parovarian  papillomata 3 

Of  these,  21  were  unilateral  and  9  were  bilateral ;  in  1  case  one  ovary  con- 
tained a  cystic  papilloma,  while  the  other  presented  solid  papillary  masses  on 
the  surface. 

Before  studying  the  characters  of  these  different  kinds  of  papillomata  sepa- 
rately, it  will  be  well  to  consider  them  briefly  from  the  broad  clinical  stand- 
point of  the  operator,  who  is,  in  fact,  too  apt  to  mingle  the  species  under 
the  general  term  papilloma,  without  recognizing  the  well-marked  individual 
characteristics. 

Relative  Frequency  of  Papillomata  and  Carcinomata. 
— While  the  ordinary  ovarian  cystoma  is  recognized  as  a  benign  growth,  the 
prevailing  opinion  classifies  the  papillomata  as  either  malignant  or  semi-ma- 
lignant— if  I  may  use  such  a  term — under  the  impression  that  they  are  in  some 
way  allied  to  the  carcinomata,  into  which  group  they  may  occasionally  pass  by  a 
species  of  degeneration.  It  must  be  borne  in  mind,  however,  that  "  malignancy" 
is  but  a  clinical  term,  while  carcinoma  is  a  purely  anatomical  expression  with  a 
strict  scientific  significance  ;  a  papilloma  has  never  been  demonstrated  to  have 
changed  into  a  carcinoma,  although  from  the  standpoint  of  the  clinician  the  fre- 
quent association  of  the  two  affections  in  one  and  the  same  tumor  might  well 
give  rise  to  such  a  suspicion.  The  malignancy  of  the  papilloma  really  refers  to 
a  group  of  symptoms  which  have  nothing  in  common  with  the  invading  de- 
structive tendencies  of  carcinoma,  but  are  simply  the  result  of  its  liability  to 
cause  extensive  ascites  and  to  become  distributed  and  implanted  in  the  form  of 
numerous  new  foci  of  growth  throughout  the  peritoneal  cavity  ;  in  time  symp- 
toms of  pressure  and  obstruction  occur,  and  nutrition  is  so  far  interfered  with  as 
to  produce  a  condition  closely  resembling  a  cachexia.  Metastases  from  the  papil- 
lomata, in  the  sense  in  which  they  occur  in  carcinomata,  have  only  been  noted 
in  the  rarest  instances.  Well-observed  cases  are  recorded  in  which  papilloma- 
tous ovaries  have  been  removed,  and  numerous  implanted  papillomatous  masses 
have  been  noted  upon  the  peritoneum,  and  yet  the  patients  have  recovered  and 
retained  perfect  health  over  a  ]ieriod  of  years  without  any  inci'ease  in  the 
growths  left  behind.  A  case  of  K.  Thornton's  remained  free  from  relapse  nine 
years  at  the  time  of  publication.  In  a  case  of  Lomer's  {Centnilh.f.  Gyn,.,  No, 
52,  1889)  two  papillomatous  tumors  the  size  of  the  double  fists  were  removed, 
leaving  warty  excrescences  scattered  over  the  intestijies  and  the  parietal  perito- 


PAPILLARY    TUMORS    OF   THE    OVARY.  267 

Tieiim,  and  four  and  a  half  years  after  the  operation  no  trace  of  a  return  of  the 
disease  could  be  detected. 

Clinical  Characteristics . — The  slowness  with  which  some  papil- 
lomata  grow  is  illustrated  by  one  of  my  own  patients  whose  abdomen  I  opened 
and  found  full  of  papillomatous  masses  choking  the  pelvis  and  covering  the 
intestines  and  abdominal  walls. 

The  tumor  masses  were  so  locked  in  the  pelvis  and  so  adherent  that  extir- 
pation was  out  of  the  question,  so  the  fluid  was  evacuated  and  the  abdomen 
closed  after  removing  a  piece  of  the  growth  for  microscopic  examination.  She 
returned  to  me  in  two  years  so  much  improved  in  her  general  condition,  and 
with  the  tumors  so  decidedly  movable  when  examined  bimanually,  that  I  re- 
opened the  abdomen  in  hopes  of  relieving  her,  but  only  to  find  the  conditions 
about  as  they  had  been  at  the  first  operation.  She  died,  finally,  about  three 
years  from  the  time  I  first  saw  her,  with  the  disease  in  an  advanced  state. 

The  manner  in  which  the  papillomata  implant  themselves  upon  the  perito- 
neum, sprout  out  into  its  cavity,  and  tend  to  choke  its  lumen,  presents  an  inter- 
esting analogy  between  tumors  of  this  sort  and  the  intracanalicular  adenomata 
of  the  breast,  which,  of  course,  are  to  be  classed  as  benign. 

In  a  series  of  1,200  abdominal  sections  for  all  causes  I  find  31  papillomata. 

Out  of  400  ovariotomies  Pfannenstiel  {Arch.f.  Gyn.,  Bd,  xlviii,  p.  507)  col- 
lected 60  papillomata — that  is  to  say,  about  15  per  cent ;  and  of  the  60  papillo- 
mata, 29  were  bilateral  and  26  were  located  only  on  one  side,  in  3  there  were 
indications  of  the  earliest  phases  of  the  new  growth,  and  2  remained  uncertain. 
In  10  out  of  89  papillomatous  tumors  the  disease  was  confined  to  the  surface 
of  the  ovary  ;  in  4  out  of  60  cases  there  was  a  superficial  papilloma  on  one 
side  and  on  the  other  a  papillary  cystoma.  This  important  clinical  fact  goes  to 
prove  that  no  anatomical  distinction  can  be  drawn  between  papilloma  in  the 
ovary  and  papilloma  on  the  ovary,  as  has  been  sometimes  attempted. 

In  about  one  third  of  the  cystic  papillomata,  masses  are  also  found  on  the 
outer  surface  of  the  tumor.  A  further  fact,  which  tends  to  do  away  with  the 
distinction  between  the  solid  papillomatous  masses  growing  on  the  surface  of  the 
ovary  and  those  growing  within  the  cysts,  is  the  discovery  of  Graafian  follicles 
choked  with  papillomata,  which  then  sprout  through  the  folhcle  wall  and  so 
come  to  spread  out  over  tlie  surface  of  the  ovary. 

The  average  age  of  33  cases  treated  by  me  was  42-5  years,  the  oldest  was 
fifty-six,  and  the  youngest  twenty-six. 

About  a  third  of  the  papillomatous  c  y  s  t  o  m  a  t  a  as  found  at  opera- 
tions are  unilocular,  but  they  exhibit  for  the  most  part  traces  of  atrophied  par- 
titions upon  their  walls,  showing  that  the  one  cyst  was  the  result  of  a  fusion  of 
cysts  earlier  in  the  history  of  the  growth. 

These  growths  vary  in  size  from  little  bodies  only  found  under  the  micro- 
scope up  to  tumors  the  size  of  a  child's  or  an  adult's  head ;  large  tumors  like  the 
classical  ovarian  cysts  are  rare. 

The  greatest  abundance  of  papillomatous  masses  is  found  in  the  smaller 
tumors ;  in  the  larger  they  are  apt  to  be  more  or  less  thinly  distributed  over  the 
5'J 


268 


OVARIOTOMY. 


walls  and  most  abundant  at  the  hilum,  where  the  blood  supply  is  richest.  One 
of  their  chief  characteristics  is  the  frequent  occurrence  of  little  chalky  bodies  on 
the  surface  or  in  the  tumor  walls ;  these  resemble  the  psammomata  described  by 
Virchow,  and  have  been  looked  upon  as  a  form  of  degeneration  peculiar  to  this 
group.  Williams  has,  however,  pointed  out  the  fact  that  they  may  be  found  in 
widely  differing  conditions,  and  Pfannenstiel  looks  upon  them  as  evidences  not 
of  deo;eneration  but  rather  of  an  excess  of  nutrition. 


Fig.  412. — Inner  Surface  of  a  Papillo-adeno-ctstoma  of  the  Left  Ovary. 

Showing  papillary  masses  growing  in  clusters  and  in  small  isolated  nodules.    March  8,  1894.    Path. 
No.  202.    %  natural  size. 


The  rapidity  of  the  growth  varies  remarkably.  In  some  cases  the  tumors 
seem  to  develop  slowly  for  months  or  years,  and  then  begin  to  increase  rapidly 
in  size.  Statements  made  by  the  patients  themselves,  however,  can  only  be  ac- 
cepted with  due  allowances  for  their  powers  of  observation ;  quite  often  it  is  the 
sudden  accumulation  of  fluid  in  the  peritoneum  which  induces  the  patient  to 
think  that  the  tumor  itself  has  grown  rapidly. 

Twice  I  have  been  able  to  follow  the  patient  from  the  time  the  tumors  were 
small,  just  felt  on  the  pelvic  floor  behind  the  l)road  ligaments. 

In  one  case  (J.  II.  E.,  San.  59,  Aug.  16,  1893)  the  mass  behind  the  left  broad 


PAPILLARY    TUMORS    OF    THE    OVARY,  269 

ligament  vras  4  centimeters  in  diameter,  sjDherical,  clearly  cystic,  and  adherent. 
The  patient  returned  to  me  after  two  years,  considering  herself  in  fair  health, 
but  an  examination  showed  that  the  pelvis  was  choked  by  tumors,  now  spring- 
ing  from  both  sides  and  extending  out  into  the  lower  abdomen.  At  the  opera- 
tion I  was  utterly  unable  to  remove  the  adherent  masses  and  the  numerous 
implantation  nodules,  and  in  five  months  more  the  patient  died  of  exhaustion. 

In  another  instance  I  made  an  examination  for  severe  pelvic  pain  associated 
with  an  unaccountable  weakness,  and  found  small  adherent  masses  behind  both 
broad  ligaments ;  there  was  no  demonstrable  ascites,  but  in  three  months  more 
the  abdomen  became  enormously  distended  with  fluid,  and  an  operation  was  for 
this  reason  imperative.  The  fluid  was  evacuated  and  the  adherent  papillary 
ovarian  tumors  removed,  but  numerous  small  implantation  foci  peppered  over 
the  bladder  and  pelvic  peritoneum  were  left  behind ;  all  went  well  until  the 
twelfth  day,  when  she  suddenly  sat  u^  in  bed  gasping  for  breath,  and  then  fell 
back  dead  from  a  pulmonary  embolus. 

In  a  case  (C.  K.,  2592)  operated  on  Feb.  IT,  1894,  I  removed  IT  liters 
of  free  fluid.  The  patient  was  forty-one  years  old  and  complained  of  continu- 
ous emaciation  accompanied  by  an  abdominal  enlargement.  Four  months  be- 
fore, her  menses  had  suddenly  ceased.  She  had  some  pain  on  defecation,  but 
none  at  any  other  time.  The  abdomen  was  enormously  symmetrically  distended 
by  an  ascites  which  lifted  the  walls  so  far  away  from  the  spine  that  no  tympany 
could  be  elicited  anywhere  below  the  umbilicus.  The  circumference  was  145 
centimeters  (58  inches).  The  superficial  veins  were  distended  and  there  was 
edema  of  the  skin  above  the  symphysis. 

Ko  tumor  could  be  felt  by  the  vagina,  but  by  the  rectum  I  found  an  irreg- 
ular ill-defined  growth  which  felt  like  papillary  masses.  The  abdomen  was 
opened,  and  after  draining  out  the  ascitic  fluid  two  papillary  cystic  tumors,  in- 
volving both  ovaries,  were  removed.  The  left  side  was  easily  elevated,  but  the 
right  had  to  be  separated  from  dense  adhesions  to  the  broad  hgament  and  pos- 
terior surface  of  the  uterus.  Adhesions  were  also  severed  between  the  bladder 
and  the  broad  ligament. 

The  pelvic  floor  and  the  rectum  were  the  seat  of  numerous  secondary  de- 
posits, eight  of  which  were  excised,  but  the  others  had  to  be  left,  as  they  covered 
such  a  wide  space.  The  patient  was  discharged  in  thirty-one  days,  rapidly  re- 
gaining strength. 

The  tumor  of  the  right  side  was  made  up  of  several  cysts,  bluish-white,  but 
translucent  and  yellowish  in  the  dependent  part  (see  Fig.  413).  On  the  surface 
was  a  pink  cauliflower-Hke  excrescence,  as  seen  in  the  figure,  and  on  the  inside 
the  smooth-walled  cysts  were  dotted  everywhere  with  outgrowths  of  varying 
sizes.     The  fluid  was  thick  and  tenacious. 

I  found  ascites  in  eleven  of  my  cases.  The  fluid  is  watery,  thick,  syrupy, 
glutinous  or  pseudomucinous  ;  it  is  often  glairy,  straw-colored,  or  red  or  chocolate- 
colored,  due  to  the  admixture  of  blood. 

A  patient  seen  by  Dr.  M.  Sherwood,  in  Oct.,  1896,  complained  of  general 
weakness  without  any  local  symptoms  at  all ;  she  returned  within  four  months 


270 


OVARIOTOMY. 


with  the  abdomen  generally  distended,  and  on  making  an  exploratory  incision  1 
found  the  entire  pelvis,  both  true  and  false,  choked  by  papillomatous  masses, 
which  were  beginning  to  break  down  extensively  in  the  center.  Enucleation  was 
impossible,  and  she  died  about  a  week  later  of  an  intense  septic  peritonitis,  pro- 
duced by  rupture  of  an  abscess  into  the  abdominal  cavity.  Her  sister  had  pre- 
viously died  under  my  care  with  the  same  disease. 


Fig.  413. — Cysto-papilloma  of  the  Ovaky,  with  Papillomatous  Masses  within  the  Cysts  as  well  as 

ON  THE  Surface. 

Both  ovaries  were  involved.     No.  174.     Natural  size. 

Histology . — Histologically  the  papillary  excrescences  consist  of  connec- 
tive tissue  covered  by  epithelium  ;  the  connective  tissue,  however,  is  but  the 
framework  which  supports  the  epithelial  growth.  \  An  examination  of  the  pa- 
pilla in  its  earliest  stages  shows  that  it  begins  by  a  proliferation  of  the  epithe- 
lium, and  as  this  pushes  out  from  the  surface  and  then  branches,  and  branches 
again,  the  connective  tissue  follows  it,  lying  beneath  the  surface  and  carrying  the 
blood  and  lymph  vessels.  Because  of  this  fact,  that  the  tumor  is  primarily  epi- 
thelial in  its  histogenesis,  it  might  be  suitably  named  a  papillary  epithelioma,  but, 
as  Pfannenstiel  suggests,  the  name  epithelioma  is  so  indelibly  associated  with  car- 
cinoma that  it  is  better  to  call  the  growth  an  adenoma.  The  appearance  of 
papilloma  is  in  fact,  in  cross-section,  that  of  a  tissue  everywhere  interpenetrated 
by  glands. 

A  further  clinical  distinction  may  be  made  between  the  papillary  adenomata 
in  which  the  epithelial  outgrowth  is  spread  out  on  the  surface  of  the  ovary  and 
those  in  which  the  epithelial  multiplication  is  in  cystic  spaces  within  the  ovary  ; 


:'&f^ 


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DESCRIPTION  OF  PLATE  XV 


A  section  of  a  small  nodule  taken  from  the  inner  surface  of  the  tumor  (Fig.  413). 
The  cyst  wall  (d)  is  made  up  of  wavy  fibrous  tissue  poor  in  blood  vessels,  and  is  lined 
on  its  inner  surface  by  a  single  layer  of  cylindrical  epithelium.  The  papillary  tree 
shown  springing  fi-om  the  cyst  wall  likewise  has  a  connective  tissue  framework  cov- 
ered by  a  single  layer  of  cylindrical  epithelium,  in  places  cut  slantingly.  Blood  ves- 
sels are  few.    The  drawing  is  an  exact  reproduction  of  the  specimen  cell  for  cell. 


X  70 


N^^;^"'. 


MBrodel.fec 


Lilh  LPranJiCo.Boslro.U5A. 


PAPILLARY    PAROVARIAN    CYST.  271 

these  two  forms  may  be  distinguished  by  the  suitable  names  adenoma  pa- 
pilla re    superficiale    and    cyst-adenoma    papilla  re. 

In  sharp  and  interesting  contrast  to  these  glandular  epithelial  tumors  stand 
a  group  of  little  tumors  of  the  ovary  in  which  the  connective-tissue  elements  are 
greatly  in  excess  of  the  epithelial ;  these  appear  sometimes  in  the  form  of  a  mush- 
room-like reddish  excrescence  on  the  surface  of  the  ovary,  apparently  sprouting 
out  from  a  ruptured  Graafian  follicle.  These  growths  are  fully  supplied  with 
blood  vessels  and  made  up  of  a  mass  of  connective  tissue  with  just  enough  epi- 
thelium to  cover  them,  and  may  be  suitably  termed  papillary  fibromata. 

Diagnosis . — The  diagnosis  of  a  papillary  tumor  can  not  be  made  when 
the  papillomata  are  confined  to  the  interior  of  an  ovarian  cyst.  The  only  j)rac- 
tical  conclusion  which  can  be  drawn  in  reference  to  such  cases  is  that  any  ova- 
rian cyst  is  liable  to  be  papillomatous  and  therefore  malignant,  and  ought  for 
this  reason  to  be  removed  as  soon  as  possil)le. 

Monocystic  and  small  nodular  ovarian  tumors  fixed  in  the  pelvis  are  always 
more  open  to  suspicion  than  are  the  larger  polycystic  tumors. 

A  probable  diagnosis  may  be  made  when  such  small  irregular  cystic  tumors 
are  found  on  both  sides,  adherent  to  the  pelvic  floor,  especially  if  they  are  asso- 
ciated with  ascites.  The  masses  lack  the  density  of  a  pelvic  abscess,  and  are 
harder  and  more  irregular  than  a  hydrosalpinx. 

It  is  also  possible  sometimes  to  feel  the  papillary  masses  distinctly  through 
the  rectum,  and  so  to  make  a  diagnosis. 

When  the  disease  has  progressed  far  enough  to  produce  irregular  masses  felt 
through  the  abdomen  with  ascites,  the  diagnosis  will  rest  between  carcinoma  and 
papilloma  of  the  peritoneum.     I  do  not  know  any  way  of  distinguishing  them. 

The  most  characteristic  symptom  is  the  emaciation  and  extreme  weakness, 
associated  with  ascites  and  ill-defined  large  masses  in  the  lower  abdomen,  choking 
the  pelvis. 

Often  when  the  disease  is  entirely  masked  by  an  ascites  it  will  be  easily  out- 
lined through  the  flaccid  abdominal  walls  after  drawing  off  the  fluid. 

I  would  warn  against  any  but  the  gentlest  handling,  to  avoid  the  risk  of 
bruising  or  breaking  off  pieces  of  the  growth  and  so  provoking  hemorrhage.  One 
large  tumor  had  such  thin  walls  that  it  broke,  as  soon  as  I  touched  it,  through  the 
incision,  discharging  into  the  peritoneum  a  brownish  fluid  full  of  ejiithelial  cells. 

The  bloody,  syrupy  liquid  withdrawn  from  the  abdomen  is  suggestive  of 
papilloma,  but  I  have  not  found  any  help  from  a  microscopic  examination  of  it. 

Papillary  Parovarian  Cyst. —  Papillary  parovarian  cysts  are  rare;  the  mono- 
cystic  papillary  cyst-adenomata  are  undoubtedly  often  mistaken  for  parovarian 
cysts  under  the  prevailing  tendency  to  ascribe  all  monocystic  tumors  to  the 
parovarium  without  a  critical  examination. 

Pfannenstiel  found  three  parovarian  papillary  cysts  in  forty-eight  cases  of 
papillomata ;  two  of  them  were  unilocular,  thin-walled  cysts  as  large  as  the  preg- 
nant uterus  at  term.  The  contents  of  the  cyst  are  typical  of  the  parovarian 
tumors,  and  on  the  interior  the  ciliated  epithelium  is  well  preserved.  The 
papillary  masses  were  small  and  few.     In  two  out  of  three  cases  the  tumors 


272 


OVARIOTOMY. 


were  known  to  have  existed  for  twelve  years  before  the  operation,  and  in  no 
case  was  there  any  evidence  of  malignancy. 

Papillary  Cystic  Graafian  Follicle. — In  two  cases  of  enlarged  Graafian  follicles 
Pfannenstiel  found  low  warty  papillse  made  up  of  a  firm  connective-tissue 
stroma  poor  in  vessels,  and  covered  by  a  low  cylindrical  epithelium  in  one  layer. 
In  one  case  the  tumor  removed  by  Fritsch  had  been  found  twelve  years  previ- 
ously by  Spiegelberg.     These  tumors  show  no  signs  of  malignancy. 

Pseudomucinous  Papillary  Adenoma. — This  group  of  papillary  tumors  re- 
sembles in  external  appearance  the  classical  polycystic  ovarian  cysts  and  really 
belongs  in  the  same  class  with  them.  They  are  multilocular  in  their  arrange- 
ment, but  as  a  rule  the  large  cyst  so  often  found  in  other  cystomata  is  wanting, 
being  replaced  by  a  number  of  small  cysts ;  these  contain  pseudomucin,  varying 
in  consistence  with  the  amount  of  water  contained,  and  in  color  from  clear, 
dirty,  or  yellowish,  to  brown  or  greenish. 

Tlie  tumors,  as  a  rule,  have  a  well-defined  pedicle,  and  show  a  decided  ten- 
dency to  grow  in  pairs  (over  50  per  cent  of  the  cases). 

The  papillary  growths  are  for  the  most  part  confined  to  the  cystic  spaces 
and  are  more  abundant  in  the  neighborhood  of  the  pedicle,  where  the  nutrition 
is  most  abundant. 

The  pseudomucin  is  a  direct  secretion  from  the  epithelial  cells  and  not  a 
form  of  degeneration.  The  growth  of  these  tumors  is  slow  and  not  accompanied 
by  marked  discomforts ;  indeed,  their  tendency  is  throughout  benign,  in  marked 

contrast  to  the  papillary  adenomata 
of  the  next  group,  with  ciliated 
epithelium,  and  to  the  papillary 
carcinomata.  In  seven  cases  im- 
plantations on  the  peritoneum  were 
found  but  once,  in  spite  of  the 
presence  of  papillary  excrescences 
on  the  surface  of  the  tumor  in  a 
number  of  instances.  In  the  case 
in  which  the  implantations  were 
found  they  appeared  as  little  glassy 
nodules  which  were  not  papillary, 
but  resembled  those  sometimes 
found  with  the  ordinary  ovarian 
cystomata. 

Simple    Papillary    Adenoma. — 
These  tumors  are  often  called  cil- 
iated   papillary    tumors,    but,    as 
pointed  out  by  Williams,  the  pres- 
ence or  absence  of  cilia  does  not  appear  to  be  important,  and  the  same  tumors 
are  often  ciliated  in  some  places  and  not  in  others. 

Over  one  third  of  the  papillary  tumors  examined  by  Pfannenstiel  belonged 
to  this  group,  and  in  about  half  of  them  the  tumors  were  bilateral ;  in  three 


Fig.   414.— Solid   or    Fibroid   Papillary   Adenoma   of 
THE  Ovary. 

On  section  the  tumor  consists  of  fibrous  stroma  enclos- 
ing alveolar  spaces  from  0-3  to  1  centimeter  in  diameter, 
which  are  completely  filled  with  branching  papillary 
masses.  Color,  pinkish  gray.  Numerous  adhesions.  Spec. 
1265.     Natural  size. 


PAPILLARY    ADENO-CARCINOMA.  273 

instances  the  tumor  of  one  ovary  was  superficial  while  the  other  side  presented 
a  papillary  cyst-adenoma. 

The  superficial  form  attains  the  average  maximum  size  of  a  man's  fist,  and 
the  cystoma,  mostly  multilocular,  grows  larger,  rarely  reaching,  however,  the  size 
of  the  pregnant  uterus  at  term. 

The  contents  of  the  tumors  are  usually  a  cloudy,  thin  serous  fluid,  never 
pseudomucinous.  Necrosis  and  tlie  exfoliation  of  the  epithelial  cells  may  jDro- 
duce  a  yellowisli  mixture. 

The  epithelium,  ciliated  or  not,  is  like  that  of  the  normal  uterine  mucosa. 

About  half  of  these  tumors  have  well-defined  pedicles,  while  the  other  half 
grow  down  between  the  folds  of  the  broad  ligament,  and,  as  a  rule,  do  not  pro- 
ject free  into  the  peritoneal  cavity. 

There  can  be  no  relapse  after  complete  extirpation,  and  implanted  colonies 
grow  slowly. 

Papillary  Adeno-carcinoma. — ^In  this  group  are  classed  all  those  tumors  which 
microscopically  show  a  departure  from  the  type  in  the  size,  form,  and  arrange- 
ment of  the  epithelial  cells,  whether  upon  the  papillae,  or  on  the  inner  surfaces 
of  the  cyst  walls,  or  in  the  walls  of  the  tumor  itself. 

Pfannenstiel  found  that  almost  half  of  his  cases  were  papillary  adeno- 
carcinomata,  while  in  twenty -seven  of  my  own  cases  I  found  but  two  of  this 
kind,  a  difference  which  it  is  difficult  to  explain. 

These  tumors  are  almost  exclusively  cystic.  In  one  case  there  was  a  cysto- 
carcinoma  of  one  side  and  a  superficial  papilloma  of  the  other. 

In  half  the  cases  the  proliferations  were  found  both  in  the  cysts  and  on  the 
surface,  without  any  evidence  of  perforation  or  rupture ;  hard  carcinomatous 
nodules  are  often  evident  in  the  cyst  wall. 

In  half  the  cases  the  tumors  were  monocystic  and  more  or  less  spherical,  and 
in  the  other  half  they  were  polycystic. 

The  picture  under  the  microscope  is  usually  that  of  an  adeno-carcinoma; 
medullary  carcinoma  is  sometimes  seen. 

True  metastases  were  observed  in  six  out  of  twenty  cases,  in  the  retroperito- 
neal and  inguinal  glands,  in  the  tube,  the  uterine  wall,  the  stomach,  the  liver, 
and  the  periosteum  of  the  ribs. 

In  one  case  there  were  double  ovarian  papillary  cysto-carcinomata,  with  car- 
cinoma of  the  cervix,  in  a  uterus  containing  numerous  myomata. 

Peritoneal  implantations  were  found  in  30  ])er  cent  of  the  cases — more  than 
twice  as  often  as  in  the  pseudomucinous  tumors,  and  in  still  further  remarkable 
contrast  to  the  latter  group  these  implantations  from  the  adeno-carcinomata 
partake  of  the  nature  of  the  mother  tumor,  and  are  markedly  malignant,  dis- 
tributing themselves  widely,  and  rapidly  2>enetrating  into  the  subjacent  tissues. 
True  cachexia  is  often  seen. 

Implantations  occur  only  when  the  papillomata  are  found  in  the  outer  surface 
of  the  tumor,  or  when,  as  in  one  case,  some  of  the  contents  of  the  tumor  escaped 
into  the  abdomen  during  the  operation.  In  this  case  the  patient  died  a  few 
months  later  of  the  peritoneal  infection. 


274 


OVARIOTOMY. 


About  82  per  cent  of  the  patients  died  of  relapse  on  an  average  of  eight 
and  a  half  months  after  the  operation,  in  sharp  contrast  to  the  simple  adeno- 
mata where  papillomata  were  left  in  the  peritoneum,  and  where  the  average 
length  of  life  was  three  and  a  half  years. 

Papillary  Cyst-adeno-sarcoma. — Only  two  cases  of  tliis  kind  are  recorded,  one 
by  Pfannenstiel  (p.  599)  and  one  of  my  own. 

The  first  case  was  that  of  a  single  woman  of  forty-seven,  from  whom  an  ex- 
tensive subperitoneal  tumor  was  removed  the  size  of  a  man's  head. 

She  died  four  months  later,  but  it  could  not  be  ascertained  whether  she  had 
a  relapse.  The  tumor  removed  was  a  unilocular  cyst,  with  a  wall  in  one  place  2 
centimeters  thick,  at  which  point  the  surface  was  covered  with  numerous  sepa- 
rate papillary  excrescences.  On  section  the  tissue  appeared  homogeneous  with 
some  irregular  cavities  with  a  smooth  wall.  The  tumor  was  made  up  of  a 
vascular  connective  tissue  interpenetrated  with  round  and  spindle  cells.  The 
papillomata  were  purely  adenomatous  in  form,  delicately  constructed  and 
covered  with  a  simple  cylindrical  epithelium  in  a  single  layer,  which  also  sent 
numerous  glandular  extensions  into  the  underlying  tissue.  There  was  no  trace- 
able connection  between  the  papillomata  and  the  sarcoma. 


'^^rSSSS^.' 


-e^r 


Fig.  415. — Adexo-carcinoma  (Colloid  Carcinoma)  of  the  Ovary,  with  Numerous  Carcinomatous 
Nodules  on  the  External  Surface  of  the  Unruptured  Cysts;  Secondary  Growths  in  the 
Omentum.     No.  328.     %  Natural  Size. 


In  a  rare  case  occurring  in  my  own  clinic  a  multilocular  adeno-papilloma 
was  found  associated  with  sarcomatous  nodules  in  the  inner  surface  of  one  of  the 
cysts.     (See  Dr.  T,  S.  Cullen,  Amer.  Jour,  of  Obs.,  vol.  xxxiv,  1896.) 


#*^ 


PLATE  XVI. 


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Fig.  2. 


X570 


tf 


Rg.3 


BHte-,  fee. 


Helioiype  Pr.ntmg  Ca,  Boston 


DESCRIPTION  OF  PLATE  XVI. 

A   PAPILLARY   OVARIAN  CYST   EXHIBITING   A  FEW  SARCOMATOUS  NODULES. 

Fig.  1  represents  a  portion  of  the  great  cyst  wall,  twice  enlarged.  In  the  left  lower 
corner  the  typical  appearance  of  a  papillary  cyst  is  seen,  while  in  the  left  upper  corner 
and  on  the  right  border  the  smooth  but  slightly  undulating  surface  of  the  cyst  wall  is 
visible.  The  sarcomatous  masses  occupy  the  center  of  the  field  in  the  form  of  a  large, 
domelike  nodule ;  to  the  right  and  above  this  a  somewhat  smaller  nodule,  and  below 
on  the  right  three  more  nodules. 

Fig.  2  is  a  cross-section  of  the  same.  On  the  left  delicate  papillary  masses  are  seen, 
in  the  middle  a  large  sarcomatous  nodule  with  smaller  ones  beside  it,  and  between 
some  of  them  are  a  few  delicate  papillary  growths. 

Fig.  3  is  a  highly  magnified  portion  of  a  sarcomatous  nodule.  In  order  to  appre- 
ciate the  size  of  the  cells  it  is  only  necessary  to  contrast  them  with  the  small,  round, 
deeply-staining  nuclei  scattered  throughout  the  tissue,  which  are  the  mononuclear 
leucocytes  ;  the  small  black  mass  just  above  the  center  of  the  field  is  the  horseshoe- 
shaped  nucleus  of  a  polymorpho-nuclear  leucocyte.  The  majority  of  the  sarcoma  cells 
have  round,  oval,  or  irregularly  oval,  rather  deeply-staining  nuclei,  and  in  the  nuclei 
the  coarse  and  fine  chromatin  granules  are  easily  demonstrable.  Surroufading  these 
nuclei  is  a  variable  amount  of  pale  staining  protoplasm.  In  the  left  lower  corner  is  an 
irregular  plaque  of  protoplasm  containing  eight  nuclei ;  in  the  vicinity  of  the  right 
lower  corner  an  almost  circular  protoplasmic  mass  with  an  irregular,  deeply  staining 
nucleus.  Just  above  and  to  the  left  of  this  is  an  irregular  plaque  of  protoplasm  con- 
taining a  deeply  stained  nucleus,  and  to  either  end  of  this  secondary  nuclei  are  attached 
by  delicate  filaments.  S(;attered  throughout  the  field  are  numerous  similar  cells,  all 
showing  karyorhexis.  A  striking  cell  is  seen  just  above  and  to  the  right  of  the  center, 
markedly  irregular  in  contour,  with  a  distinct  nucleus,  and  containing  many  coarse 
granules  of  chromatin. 

Fig.  4  shows  a  sarcomatous  nodule  on  section,  magnified  forty  times,  with  the  papil- 
lomata  on  either  side.  The  underlying  connective  tissue  is  poor  in  cell  elements  and 
contrasts  sharply  with  the  superficial  sarcoma,  whose  cells  are  abundant.  The  nuclei 
are  round  or  irregular,  and  in  the  pale  staining  area  large. 


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CARCINOMA  OF  THE  OVARY. 


275 


The  patient  (M.  G.,  3100,  Oct.  13,  1S94)  was  sixtj-three  years  old,  and  was 
operated  upon  Oct.  13,  1894,  for  a  tumor  which  she  had  noticed  for  the  first 
time  six  months  before.  A  cyst  about  the  size  of  a  man's  head  was  removed 
from  the  right  side  close  to  the  uterine  cornu,  and  an  uninterrupted  recovery 
followed.     (See  Plate  XYI.) 

Carcinoma  of  the  Ovary, 
ovarian  diseases. 


A.deno-carcinoma  is  the  most  malignant  of  all  the 


Fig.  416. — Cysto-carcinoma  of  the  Ovary  of  Unusual  Form. 

The  walls  are  thick,  and  the  inner  surface  of  the  large  cyst  is  smooth,  irregular,  nodular,  and  ha.s  no 
epithelial  lining.    The  uterine  tube  lies  above.     No.  344.    %  natural  size. 

It  is  an  epithelial  growth  appearing  under  several  forms,  either  primary — 
that  is,  originating  in  the  ovary  and  constituting  the  original  ovarian  tumor — or 
secondary,  in  two  ways :  first,  as  a  degeneration  of  a  glandular  ovarian  cyst,  a 
dermoid,  or  a  papillary  cyst,  or  second,  metastatic  from  some  other  organ,  such 
as  the  body  of  the  uterus  or  the  cervix. 

The  association  of  carcinoma  with  the  glandular  and  the  papillary  cystoma, 
although  unexplained  in  its  etiology,  seems  but  a  natural  evolution  of  these 
histologically  remarkable  growths,  characterized  as  they  are  by  an  enormous 
proliferation  of  atypical  "glandular"  tissue. 


276 


OVARIOTOMY. 


The  carcinoma  appears  in  a  solid,  scirrhus,  or  in  a  cystic  form,  and  is  found 
in  young  patients  and  after  the  chmacteric. 

The  epithehum,  cylindrical  at  first,  becomes  atypical,  penetrates  the  under- 
lying tissues,  forms  alveoli,  and  consists  of  many  layers. 

Out  of  thirteen  cases  of  primary  ovarian  carcinoma  occurring  in  my  practice, 

four  were  double  and  nine  were  sin- 
gle ;  these  were  again  subdivided  into 
six  solid  and  seven  cystic  tumors. 

There  were  two  cases  of  papil- 
lary cystic  carcinoma  and  one  case 
of  papillary  solid  carcinoma. 

The  tumors  vary  in  size  from 
small    growths    scarcely    enlarging 
the  ovary  to  a  mass  as  large  as  a 
man's  head.     The   development   is 
rapid,  produces  metastases  in  vari- 
ous parts  of  the  body  by  lymph  and 
blood  channels,  and  invades  and  de- 
stroys the  surrounding  and  subja- 
cent tissues ;  the  omentum  is  par- 
ticularly  liable   to   metastases ;    on 
the  intestine  they  often  appear  as 
round,  white,  hard,  and  flat- tipped 
bodies  variously  grouped. 
As  the  disease  develops,  edema  of  the  legs  and  cachexia  become  marked. 
Secondary  Carcinoma . — There  is  sufficient  clinical  evidence  to  show 
that  the  ovary  may  become  the  seat  of  carcinomatous  metastases,  which  partake 
of  the  characters  of  the  primitive  growth,  but  this  secondary  involvement,  how- 
ever, would  seem  to  be  rare. 

A.  Hempel  records  a  case  {Arch.f.  Gyn.,  viii,  p.  56)  in  a  woman  of  forty- 
two  in  whom  ovarian  carcinomata  of  both  ovaries  were  found  at  the  end  of  preg- 
nancy;  a  fully  developed  living  child  was  born,  and  .,  ,l; 
the  patient  died  a  month  later  of  a  purulent  perito- 
nitis.   Both  ovaries  were  found  converted  into  irreg-        f.i    '. 
ular  nodular  tumors  larger  than  a  child's  head,  and 
at  the  pylorus  there  was  a  carcinoma  of  long  stand- 
ing with  a  perforation  1  centimeter  in  diameter. 

P.  Reichel  {Zeits.f.  Geh.  \md  Gyii.,  xv,  p.  354) 
shows  the  remarkable  possibility  of  a  metastasis  di- 
rect from  a  carcinomatous  uterus  to  the  ovary  in 
cases  in  which  the  protracted  uterine  hemorrhages 
gave  satisfactory  evidence  of  the  existence  of  the 
uterine  carcinoma  prior  to  that  of  the  ovary.  He  further  urges  that  such  a 
combination  is  more  frequent  than  is  generally  believed,  and  that  it  should 
always  be  borne  iu  mind  and  looked  for  in  all  cases  of  ovarian  carcinoma. 


Fig.  417. — Flat  l  AKrixoM.vxors   .Metastatic   iSudules 
ON  THE  Intestines. 

Note  the  tendency  to  a  circular  arrangement  along 
tlie  lymphatic  ves.sels.  Autopsy  Jan.  9,  1897.  %  natu- 
ral size. 


Fio.  419. —  Adeno-carcinoma  of 
THE  Omentum,  seen  in  Section. 
No.  328.  Natiral  Size.  See 
Fig.  418. 


Fig.  418. — Large  Adeno-cakcinoma  (Colloid  Carcinoma)  of  tub  Omentum,  Secondary  to  Carcinoma  of  the  Ovart;  the 

Free  Border  of  the  Omentum  is  Below. 

Operation  removing  omental  mass.    Kecovery.    Death  some  months  later.    No.  328.    J^  natural  size. 


Fig.  420. — Rudimentary   Jaw   from   a   Dermoid   Cyst   containing   Molar   Teeth,  and  with   a   wisp  of 
Brown  Hair  growing  from  one  Extremity. 

On  the  right  is  anotlier  small  piece  of  dentigerous  bone  loaded  with  molar  teeth.     Case  of  Dr.  Weist. 
Natural  size. 


DEKMOID    CYSTS   OF   THE   OVARY. 


27Y 


On  the  other  hand,  in  carcinoma  of  the  bodj  of  the  uterus  the  ovaries  should 
be  removed  too,  on  account  of  the  possibility  of  an  early  metastasis,  not  yet 
recognizable  to  the  naked  eye. 

Dermoid  Cysts  of  the  Ovary. — A  dermoid  ovarian  cyst  is  an  ovarian  tumor 
containing  some  or  all  of  the  elements  of  skin  tissue,  bones,  nerves,  and  mucous 
membrane ;  it  is  usually  unilocular,  and  exhibits  more  or  less  perfectly  the  epi- 
thelial layers  of  the  skin,  with  sebaceous  and  sweat  glands  and  hair.  Teeth  are 
often  found  imbedded  in  the  cyst  wall,  sometimes  attached  to  bone  structure, 
with  a  well-defined  alveolar  process  closely  resembling  a  part  of  the  lower  jaw. 
Cartilage,  nerves,  and  brain  tissue  have  been  found  in  these  cysts,  and  in  one 
instance  nail  tissue.     A  mamma  with  well-developed  nipple  has  been  observed. 

The  outer  covering  of  the  tumor  is  like  that  of  an  ordinary  ovarian  cyst,  and 
in  its  general  relationships  the  dermoid  cyst  is  in  all  respects  similar  to  a  uni- 
locular ovarian  tumor. 

The  walls  of  the  cyst  are  lined  by  many  layers  of  squamous  epithelium,  and 
vary  from  a  thin  membrane,  almost  transparent,  to  one  that  is  thick  and  leathery, 
and  the  contents  are  oily,  thick,  and  greasy,  sometimes  cheesy,  due  to  the 


W-t  'A 


Fio.  421. — CoNTODR  OF  THE  Abdomen  in  the  Case  of  an  Uncsually  Large  Dermoid  Cyst.     No.  2766. 


secretions  of  the  sebaceous  glands  and  fatty  degeneration  of  the  epithelial  cells. 
The  color  of  the  hair  may  be  either  light  or  dark,  and  bears  no  relation  to  that 
of  the  surface  of  the  body.  It  may  be  found  in  large  quantities,  rolled  up 
loosely  in  a  ball,  immersed  in  fat.  Hairs  of  various  lengths  are  also  found 
growing  from  the  cyst  wall,  usually  not  exceeding  two  feet.  In  a  case  reported 
by  Dr.  P.  F.  Munde,  of  New  York,  the  hair  was  five  feet  long. 

After  removing  a  dermoid  cyst,  if  the  tumor  stands  in  a  cool  place  it  be- 


278 


OVARIOTOMY. 


comes  hard  and  deep  yellow  in  color ;  if  the  contents  of  a  large  cyst  are  allowed 
to  stand,  the  surface  shortly  becomes  covered  with  fine  feathery  flakes  of  choles- 
terin  crystals. 

Dermoid  tumors  of  the  ovary  are  usually  limited  to  one  side.  In  twenty-one 
cases  I  had  one  in  which  both  right  and  left  ovaries  were  involved,  and  one  in 
which  there  were  two  cysts  on  the  same  side.  In  operating  for  a  dermoid  cyst, 
if  the  opposite  ovary  is  at  all  enlarged  it  must  be  incised  to  determine  whether 
a  small  dermoid  may  not  be  concealed  within  it. 

The  size  of  the  tumor  varies  from  a  little  nodule  not  larger  than  a  distended 
Graafian  follicle  to  a  mass  filling  the  abdomen.  One  of  my  cases  was  but  2 
centimeters  in  diameter,  while  another  contained  10  liters  (20  pints)  of  fluid ; 
they  are,  however,  not  often  seen  much  larger  than  a  man's  head. 

The  cause  of  dermoid  tumors  has  not  been  satisfactorily  explained ;  the  most 
plausible  theory  is  that  of  Cohnheim,  who  attributes  their  origin  to  an  inclusion 
of  parts  of  the  outer  skin  layer  (ectoderm)  in  the  ovary  during  its  formation  in 
early  fetal  life.  These  misplaced  skin  elements  then  naturally  begin  to  grow 
during  the  period  of  greatest  ovarian  activity,  and  develop  the  various  skin 

tissues  after  an  atypical  fashion. 

In  the  examination  of  the  clinical  his- 
tory of  nineteen  of  my  cases,  I  find  that 
fourteen  women  were  mari-ied  and  five  sin- 
gle. Of  the  fourteen  married  women,  six 
were  childless,  but  three  of  these  had  had 
miscarriages.  The  ages  of  the  patients  varied 
from  twenty-one  to  sixty  years,  the  average 
being  thirty-five  years.  The  growth  of  the 
tumor  in  most  cases  was  slow ;  one  woman 
had  noticed  hers  for  ten  years  before  opera- 
tion, and  others  for  six  or  seven  years,  while 
another  had  only  known  of  its  presence  for 
three  months.  Observations  as  to  the  slow 
development  can  of  course  only  be  applied 
to  cases  in  which  the  tumor  had  already  at- 
tained a  size  sufiicient  to  produce  distention 
and  be  felt  through  the  lower  abdominal 
wall.  Where  the  tumor  lying  in  the  pelvis 
was  small  the  patients  were  unconscious  of 
the  existence  of  any  tumor. 
Out  of  seventeen  cases  the  tumors  were  found  eight  times  on  the  left  side 
and  eight  times  on  the  right,  and  once  occupying  both  left  and  right  sides. 

The  pedicle  varies  as  in  ovarian  multilocular  tumors.  Eight  cases  were 
distinctly  pediculated,  seven  had  no  pedicle  at  all,  and  one  had  a  long  twisted 
pedicle  turned  one  and  a  half  time  upon  itself. 

There  can  be  no  doiibt  that  dermoid  cysts  are  peculiarly  prone  to  induce 
attacks  of  localized   peritonitis.     This  tendency  is  diflBcult  to  explain, 


Fig.    422. — Left    Dermoid    Cyst    of    the 
Ovary  with  a  Loxg  Pedicle. 

The  cyst  (D)  lay  in  the  median  line 
and  could'  easily  be  pulled  high  up  in  the 
abdomen  or  displaced  into  eitlier  flank  in 
the  position  of  the  dotted  lines.     No.  2554. 


DERMOID    CYSTS    OF   THE    OVARY. 


279 


and  seems  inherent  even  in  the  smallest  cysts,  which  are  often  found  matted  in 
a  dense  mass  of  adhesions ;  on  the  contrary,  however,  I  have  seen  a  cyst  as  large 
as  a  man's  head  entirely  free  from  adliesions.  I  found  eight  out  of  nineteen 
cases  not  at  all  adherent,  while  the  other  eleven  were  more  or  less  fixed  by 
adhesions  varying  from  the  slight  velamentous  attachment  to  tlie  densest  fibrous 
union. 

Owing  to  this  liability  to  provoke  attacks  of  peritonitis  involving  the  im- 
mediately surrounding  structures,  inflammatory  disease  involving  the  other  ovary 
and  tube  is  frequently  found.  This  generally  consists  in  adhesions  binding 
down  the  tube  and  ovary,  often  associated  with  hydrosalpinx  (see  Fig,  423). 


Fig.  423. — Complicated  Dermoid   Cyst  of  the   Kight  Ovary,  with   Dense   Adhesions  to  the  Entire 
Breadth  of  the  Omentum  and  Displacement  of  the  Kight  Tube  and  Round  Ligament. 

The  uterus  is  dragged  up  (ascensus  uteri),  and  on  the  left  side  there  is  a  large  hj-drosalpinx.    No.  3120. 


Like  the  ovarian  cystoma,  the  dermoid  cyst  may  become  almost  completely 
detached  from  its  natural  vascular  supply  and  depend  for  its  existence  upon  the 
adhesions  formed  between  it  and  other  organs  (see  Fig.  424). 

I  have  not  been  able  to  note  anything  characteristic  in  the  menstrual  history 
beyond  the  fact  that  sixteen  of  the  nineteen  cases  complained  of  pain,  generally 
severe.  In  three  non -adherent  cases  there  was  no  pain  at  all,  but  a  distressing 
bearing-down  sensation  in  the  lower  abdomen. 

About  half  of  all  the  cases  complained  of  vesical  distress  varying 
from  a  frequent  micturition  to  a  severe  tenesmus.  A  marked  emaciation  is 
often  apparent.  One  woman  lost  40  pounds  in  six  months,  and  during  this  time 
the  abdomen  reached  a  circumference  of  92  centimeters  (30'8  inches). 

The  prognosis  if  the  tumor  is  left  to  grow  is  bad;  in  the  absence  of 
complications  the  growth  advances  until  the  abdomen  is  so  distended  that  the 


280 


OVAEIOTOMY. 


functions  of  the  abdominal,  and  later  of  the  thoracic,  organs  are  impaired  by 
pressure. 

Far  more  than  in  the  case  of  ordinary  ovarian  cysts  are  these  patients  liable 
to  attacks  of  peritonitis  resulting  in  adhesions  to  all  contiguous  structures.  Sup- 
puration of  the  cyst  is  also  not  uncommon,  followed  by  perforation  into  bladder 
(see  Yol.  I,  p.  355,  Fig.  225)  or  bowel.  On  account  of  the  adenoid  elements 
which  they  contain,  the  liability  to  cancerous  degeneration  is  also  great.  Hydro- 
nephrosis and  pyelitis  may  be  caused  by  the  pressure  of  the  cyst  on  one  or  both 
ureters.  For  one  or  more  of  these  cogent  reasons  the  patient  who  at  first  de- 
fers an  operation  will  sooner  or  later  be 
forced  to  seek  surgical  relief. 

The  diagnosis  is  usually 
difficult  to  make.  The  chief 
dijQficulty  is  in  distinguishing  a  tumor 
of  this  sort  from  an  ordinary  ovarian 
tumor.  The  difference  in  consistence 
is  of  no  aid,  as  the  contents  of  a  der- 
moid cyst  are  so  frequently  liquid  that 
they  appear  on  palpation  to  have  about 
the  same  consistence  as  water. 

The  following  points  may  be  borne 
in  mind  in  making  the  diagnosis  :  The 
dermoid  tumor  is  more  or  less  spheri- 
cal, usually  unilateral,  giving  the  im- 
pression of  being  a  monocyst ;  if  large, 
its  growth  has  been  slow.  If  the  pa- 
tient is  young,  the  chances  are  in  favor 
of  a  dermoid.  Where  attended  with 
inflammatory  sequelae  the  dermoid  is 
apt  to  be  extremely  painful  on  pres- 
sure. The  tendency  to  emaciation  must 
also  have  its  weight  in  making  the  di- 
agnosis. Ktistner's  rule  that  the  der- 
moid tumor  has  a  remarkable  tendency 
to  float  out  in  front  of  the  uterus  and 
lie  just  behind  the  abdominal  wall  was 
found  in  five  out  of  twelve  of  my  cases, 
and  is  therefore  a  valuable  diagnostic  point.  In  one  case  the  diagnosis  was 
unexpectedly  made  by  a  vaginal  puncture  under  the  impression  that  the 
fluctuating  sac  choking  the  pelvis  and  bulging  into  the  vagina  was  a  pelvic 
abscess.  The  discharge  of  fatty  matter  at  once  revealed  the  true  nature  of 
the  case. 

In  small  monocystic  tumors  not  rising  out  of  the  pelvis  the  dermoid  tumor 
must  always  enter  into  the  list  for  a  diffei-ential  diagnosis.  When  the  tumor  is 
adherent  and  there  is  a  history  of  pelvic  pains  lasting  some  years,  and  the  walls 


Fig.  424. — Eight  Dermoid  Cyst  {D)  with  Exten- 
sive Adhesions. 

Note  the  displacement  and  atrophy  of  the  riglit 
tuhe,  aiid  tlie  adhesion  to  and  antrulation  of  the  left 
tube.     Feb.  2, 1895.     No.  584.     %  natural  size. 


^0 


Fig.  425. — Parovarian  Cyst  situated  between  the  Ampulla  of  the  Tube  and  the  Outer  End  of  the  Ovary. 


The  rest  of  the  mesosalpinx  is  intact. 
Natural  size. 


The  ovary  shows  a  recently  ruptured  corpus  nigrum.     Oct.  16,  1895. 


FiQ.  426.- 


-Parovarian   Cv-i,    -u    wing  its  Translucency  and   the   Characterisj  p     i; 
Tube,  which  ib  Gi'.fcATLY  Lengthened  and  Spread  Out  on  the  SuKFAci, 


I  Allows   OF  the   Uterine 
jv  'inE  Cyst. 


sweep 


There  is  no  mesosalpinx,  and  the  fimbriated  end  is  pulled  out  loncfcr  than  the  tube  itself,  and  describes  an  arc 
jping  around  toward  the  uterine  end  of  the  tube.     Note  the  double  set  of  vessels,  superficial  and  deep.     The  pedicle 


is  at  the  area  uncovered  by  peritoneum  on  tlie  rigrht  upper  surface.     The  slightly  irregular  surface  seen  on  the  outline 
just  to  the  right  of  the  pedicle  is  the  ovary  spread  out  on  the  surface  of  the  tumor.     July  31, 1895.    3^  natural  size. 


PAROVARIAX    CYSTS. 


281 


of  the  tumor  are  evidently  thicker  tlian  those  of  a  thin  Graafian  folhcle  cyst,  a 
probal)le  diagnosis  may  be  made. 

Parovarian  Cysts. — A  parovarian  cyst  is  one  originating  in  the  tubular  remains 
of  the  embryonic  Wolfiian  body,  in  the  layers  of  the  mesosalpinx  (see  Yol.  I, 
p.  61,  Fig.  32),  between  the  uterine  tube  and  ovary;  as  the  cyst  continues  to 
grow  it  either  enlarges  as  a  free  tumor  up  into  the  abdominal  cavity,  or  first 
down  between  the  layers  of  the  broad  ligament  and  then  \\-p  into  the  abdomen, 
or  it  may  lie  altogether  behind  the  peritoneum. 

The  tubules  of  the  parovarium  are  one  millimeter  in  diameter  or  less,  and 
are  readily  seen  by  holding  the  mesosalpinx  up  to  the  Hght  while  separating 
the  tube  from  the  ovary.  Histologically,  the  tubules  are  surrounded  by  several 
layers  of  spindle  cells,  which  appear  to  be  non-striped  muscular  fibers,  and  they 
are  lined  by  a  single  layer  of  cuboidal  or  low  cylindrical  epithelium  which  is 
often  ciliated. 

Parovarian  cysts  vary  in  size  from  a  few  millimeters  to  20  or  more  centi- 
meters in  diameter.  If  small  they  may  be  multiple,  but  when  large  they  are 
almost  invariably  single.  These  cysts  are  usually  transparent,  and  are  smooth 
and  glistening.     As  the 

peritoneum  is  but  loose-  .i^^^^^^d^H^B^i^^.  ^^ 

ly  connected  with  the 
cyst  wall  by  a  delicate 
stroma,  it  can  be  readi- 
ly slid  over  the  surface 
of  the  tumor.  This  is 
due  to  the  fact  that  the 
tubules  are  situated  be- 
tween the  layers  of  the 

broad  ligament  and   are  Fig.  427.— Parovarian  Cyst,  with   Subsidiary  Cysts   lying  beneath 

1      .    1           1                      A    Vi  "^^^  Tubo-ovarian  Fimbria,  weighing   down  the  Fimbriated  End 

DUt   loosely  covered    by  of  the  Tube  and   separating  it  from  the  Ovary,  which  is  seen 

peritoneum.     The  blood  on  ^the^K^ght,  under  the   Isthmus   of  the  Tube.      July  3,  1895. 

vessels  of  the  peritone- 
um have  a  direction  differing  from  those  of  the  tumor,  so  that  the  two  well- 
defined  vascular  networks  are  seen  crossing  each  other.  The  cyst  walls  are 
usually  thin,  and  may  contain  calcareous  plates  ;  the  inner  surface  is  whitish  or 
pinkish  in  color,  smooth,  and  glistening  ;  rarely  papillary  masses  spring  from  the 
inner  wall.  The  cyst  fluid,  poor  in  albumin,  is  pale  and  limpid  like  water,  and 
its  specific  gra\dty  varies  from  1004  to  1006.  In  those  cases,  however,  where 
there  are  papillary  masses,  or  in  which  hemorrhage  has  taken  place  into  the  cyst, 
the  specific  gravity  is  higher  and  the  color  brown,  blackish,  or  yellow.  Orth 
says  that  he  has  almost  invariably  been  able  to  find  cilia  at  some  point  or  other, 
whether  the  cyst  is  large  or  small.  The  tumors  as  they  grow  tend  to  separate 
the  layers  of  the  broad  ligament  more  and  more  and  to  extend  down  to  the 
pelvic  floor,  out  toward  the  rectum  or  cecum,  and  up  into  the  abdomen  behind 
the  peritoneum.  The  relations  of  the  tube  and  the  ovary  to  the  cyst  are  charac- 
teristic.    The  tube  is  arched  over  the  upper  surface  of  the  tumor,  and  may  reach 


282 


OVAEIOTOMT. 


40  or  more  centimeters  in  length.  Its  fimbriated  extremity  often  adheres  to  the 
cyst,  but  becomes  lengthened  out  and  spread  apart.  The  ovary  is  found  as  a 
small  flattened  prominence  on  the  under  or  anterior  surface  of  the  cyst.  It 
may,  however,  be  included  in  the  cyst  walls.     The  tube  and  ovary,  apart  from 

the  flattening,  are  histo- 
logically normal. 

Out  of  one  hundred 
and  fifty  cases  of  cystic 
tumors  of  the  ovary  of 
all  kinds  in  my  own  clin- 
ic, thirty  (20  per  cent), 
including  all  broad  liga- 
ment cysts,  were  parova- 
rian. The  average  age 
was  thirty  -  nine  years, 
the  two  oldest  women 
being  seventy-five  and 
seventy  -  three,  and  the 
youngest  eighteen.  The 
majority  were  about 
thirty  -  five.  The  aver- 
age number  of  childi'en 
to  the  married  women 
was  3* 5. 

The  commonest  place 
for  the  occurrence  of 
parovarian  cysts  is  un- 
der the  outer  extremity 
of  the  tube,  separating 
the  fimbriated  end  from  the  ovary  as  the  tumor  increases  in  size,  and  thus 
acting  as  an  eflicient  cause  of  sterility. 

In  one  case  (P.  T.,  No.  604,  March  14,  1891)  there  were  two  cysts,  2|^  centi- 
meters in  diameter,  in  front  of  the  tubo-ovarian  fimbria,  and  a  third,  3  centi- 
meters in  diameter,  at  the  uterine  end  of  the  tube. 

These  small  cysts  are  almost  always  sessile  and  situated  plainly  between  the 
folds  of  the  broad  ligament.  In  one  case,  however  (L.  W.,  IIYI,  Jan.  27, 
1892),  the  tumor,  about  3  centimeters  in  diameter,  had  a  pedicle  1*5  centimeter 
long  under  the  fimbriated  end. 

The  utero-ovarian  ligament  and  the  uterine  end  of  the  tul)e  are  never  widely 
separated,  although  the  tube  itself  may  be  lengthened  out,  in  one  case  43  cen- 
timeters (17'2  inches).  It  always  describes  a  curved  course  circling  around 
toward  the  ovary,  which  can  be  found  on  the  surface  of  the  tumor  close  to  the 
pedicle  by  means  of  this  ligament.  The  fact  that  the  parovarian  cyst  is  most 
likely  to  spring  from  tlie  outer  part  of  the  parovarium  can  be  shown,  even  in  a 
large  tumor,  by  lifting  up  the  uterine  end  of  tlie  tube,  and  exposing  this  part  of 


Fig.   42S.— Parovakian   Cyst  bulging   Out   on   Both    Sides   of  the 
Tube  and  attached  to  the  Isthmus  by  Bands  of  Adhesions. 

The  tubo-ovarian  fimbria  is  splinted  over  the  surface  of  the  cyst,  ami 
on  its  upper  surface  stands  out  an  accessory  tube  with  two  pedicles. 
The  hydatid  is  well  shown,  and  the  ovary  lies  intact  beneath  the  tumor. 
March  16,  1895.     Natural  size. 


HYDATID    OF    MORGAGXI. 


283 


the  mesosalpinx,  when  a  part  of  the  parovarium  can  be  seen  in  it.  The  simple 
pediculated  parovarian  ejst  develops  from  its  point  of  origin  up  into  the  abdo- 
men -svithout  spreading  apart  the  layers  of  the  broad  ligament.  The  tumor 
is  slow  in  attaining  a  large  size,  and  is  usually  more  flaccid  than  the  ovarian 
monocysts. 

The  pedicle  may  be  several  centimeters  long  and  occupy  the  breadth  of  the 
broad  hgament.  The  ovary  is  found  in  the  under  surface  near  the  uterine  end 
of  the  tube.  Sometimes  there  is  no  pedicle,  but  the  tube  and  the  mesosalpinx 
lie  flat  on  the  surface  of  the  cyst,  and  the  ovary  near  by.  The  cyst  takes  often 
a  somewhat  cylindrical  form,  giving  the  abdomen  the  appearance  of  ascites. 

A  long  pedicle  may  un- 
dergo torsion,  as  in  the  case 
of  other  ovarian  tumors.  A 
remarkable  instance  of  tor- 
sion of  the  pedicle,  involv- 
ing the  tube  and  producing 
a  hemorrhagic  infarct  of 
both  tube  and  cyst,  is  shown 
in  Fig.  431. 

The  most  pi'ominent 
symptoms  in  my  cases  ne- 
cessitating operation  were 
the  size  of  the  tumor,  and 
pain  in  all  but  three  cases, 
described  as  dull  and  bear- 
ing down,  or  paroxysmal 
and  sharp.  Adhesions  were 
found  in  all  but  four  cases. 

The  diagnosis  may 
often  be  made  by  recalling 

the  fact  that  the  tumor  is  one  of  slow  growth,  has  a  smooth  surface  presenting 
no  bosses  or  evidence  of  secondary  cysts,  is  apt  to  be  flaccid  in  contrast  to  the 
tense  ovarian  cyst,  and  when  large  is  symmetrically  disposed  in  the  abdomen, 
which  is  more  flattened  or  cyHndroid  than  in  the  case  of  a  tense  globular  ova- 
rian cyst.  The  percussion  wave  is  less  sharp  than  in  a  tensely  filled  sac,  and 
conveys  the  impression  of  a  single  sac  with  thin  walls. 

On  opening  the  abdomen  the  clear  monocystic  accumulation  of  serum  due  to 
an  encysted  peritonitis  must  not  be  mistaken  for  parovarian  or  other  cysts. 
These  tumors  are  oftenest  found  in  cases  of  extensive  pelvic  peritonitis.  An 
unusually  large  bleb  of  this  sort  is  figured  in  the  text  (see  Fig.  432). 

Hydatid  of  Morgagni  (Appendix  Vesicular  is,  Kossmann). — 1  have 
seen  a  variety  of  interesting  affections  of  the  little  pediculated  vesicular  or- 
gan which  hangs  from  the  anterior  surface  of  the  broad  ligament  at  the  end 
of  the  longitudinal  canal  of  the  parovarium,  and  is  sometimes  known  as  the 
hydatid  of  Morgagni  (see  Fig.  428).     In  no  case,  however,  have  I  observed  any 


Fig.  429. — CrsT  of  the  Parovarium  separating  the  Ampullar 
End  of  the  Tube  from  the  Ovary.  April  6,  1895.  Natu- 
ral Size. 


284 


OVAEIOTOMY. 


condition  which  could  interfere  with  health.  The  little  organ  in  question, 
sometimes  ovoid,  sometimes  spherical,  is  about  8  millimeters  in  diameter;  at 
other  times  it  looks  like  two  vesicles  fused  together  with  a  slight  constriction 
between  them,  in  which  lie  the  vessels  and  some  of  the  tissue  of  the  pedicle. 
The  length  of  the  pedicle  varies  from  nothing  at  all,  when  the  vesicle  is  sessile 
on  the  broad  ligament,  to  one  10  or  12  centimeters  long ;  the  average  length  is 
about  3  centimeters,  when  the  pedicle  is  about  2  millimeters  in  thickness  and 
expanded  at  the  base.     The  long  pedicles  are  often  almost  threadlike.     The 


Fig.  430. — I'aiiovaeiax  Cyst. 

Showing  the  mesosalpinx  spread  out  on  both  sides  of  the  tumor,  which  is  developed  more  in  its  outer 
part,  widely  separating  tne  tubal  ostium  from  the  ovary.  The  hydatid  is  seen  above.  The  pedicle  lies  above 
the  isthmial  end  of  the  tube.     Path.  No.  240.     3/5  natural  size. 


little  vessels  can  always  be  seen  ascending  the  pedicle  and  distributed  over  the 
pellucid  surface  of  the  diminutive  cyst.  When  the  pedicle  is  long  enough  it 
will  often  be  found  han2;ing  over  the  tubo-ovarian  fimbria,  between  the  tubal 
orifice  and  the  ovary,  into  the  posterior  part  of  the  pelvis  ;  this  tendency  ex- 
plains the  following  affection,  which  I  have  seen  twice  :  The  fimbriated  end  of 
the  tube  has  adhered  to  the  tubo-ovarian  fimbria,  except  at  a  point  close  up 
under  the  tubal  orifice,  where  the  pedicle  of  the  hydatid  passed  under  it ;  by 
pulling  on  this  pedicle  it  could  be  drawn  to  and  fro  for  a  distance  of  about  a 
centimeter,  exhibiting  a  movement  resembling  the  trochlear  muscle  of  the  eye, 
but,  owing  to  a  loose  investment  of  adhesions,  it  could  not  be  moved  beyond  this 
distance  ;  the  vesicle  hung  free  on  the  other  side. 


FIBROID   TUMORS    OF   THE    OVARY. 


2S5 


1  have  several  times  found  the  pedicle  tied  in  a  single  knot  about  its  middle 
without  interfeiing  with  the  circulation. 

In  one  interesting  case,  an  ovarian  cyst,  figured  in  the  text  (Figs.  433  and 
434),  what  was  undoubted- 
ly the  pedicle  of  the  hyda- 
tid was  found  tied  around 
one  of  the  fimbriae  of  the 
utei'ine  tube ;  the  fimbria 
presented  a  dead  white  ap- 
pearance, there  were  a  few 
adhesions  around  the  pedi- 
cle at  the  point  of  con- 
striction, and  the  hydatid 
vesicle  itself  was  wanting 
(Fig.  434).  I  made  a  care- 
ful drawing  of  the  knot 
about  the  fimbria  enlarged 
under  a  low  power,  but 
when  the  specimen  reached 
the  laboratory  the  knot  had 
pulled  out  and  there  re- 
mained only  a  loop  with 
adhesions.  I  explain  the 
condition  found  in  the  fol- 
lowing way  :  A  loose  knot 
was  formed  in  the  pedicle 
of  the  vesicle,  which  proba- 
bly hung  over  the  back  of 
the  broad  ligament ;  then 
one  of  the  fimbriae  slipped 
in,  was  caught  in  the  tie 
and  strangulated,  and  the 

vesicle  and  distal  portion  of  the  pedicle,  also  strangulated,  dropped  off,  leaving 
the  knot  fixed  by  a  little  adhesive  peritonitis,  as  I  found  it. 

In  one  case  there  was  a  hemorrhagic  infarct  of  the  large  left  hydatid,  due  to 
a  pedicle  several  times  twisted  and  almost  severed. 

In  another  instance  the  long  pediculated  left  hydatid  was  adherent  to  the 
sigmoid  flexure  above  the  pelvic  brim,  forming  a  large  loop  like  a  long  band  of 
lymph. 

Fibroid  Tumors  of  the  Ovary. — These  are  among  the  rarest  of  the  pelvic 
tumors,  and  are  characterized  by  a  multiplication  of  the  connective-tissue  ele- 
ments of  the  ovary  at  the  expense  of  all  the  other  histological  constituents.  The 
entire  organ  is  usually  involved,  becoming  converted  into  a  "fibroid  ovary," 
which  may  rarely  contain  degeneration  cysts,  dilated  blood  si)aces,  and  lyni])h 
spaces. 


Fig.  431. — Parovarian  Cyst  with  Twisted  Pedicle,  with   Hem- 
orrhagic Infarction  of  the  Uterine  Tube. 

The  ovary  is  intact,  together  with  a  small  portion  of  the  uterine 
end  of  the  tube.    Gyn.  No.  1659.    Natural  size. 


286 


OVARIOTOMY. 


The  tumor  is  densely  hard,  often  almost  bony  in  consistence,  pinkish  or- 
white  in  color,  covered  with  smooth  peritoneum,  but  divided  into  lobes  by  deep 
and  shallow  furrows.  The  fibrous  growth  is  never  disposed  like  a  uterine  fibroid 
in  a  bed  from  which  it  can  be  shelled  out ;  the  connection  with  the  ovarian  stroma 
is  direct  and  shows  no  line  of  demarcation. 

Calcification  of  fibroid  tumors  of  the  ovary  occurs  in  rare  instances,  forming 
masses  usually  small  in  volume,  consisting  of  the  phosphates  and  carbonates  of 
calcium.  The  largest  mass  I  have  seen  was  shown  to  me  by  Dr.  Copeland 
in  Milwaukee,  who  at  my  request  sent  it  to  Baltimore,  where  it  was  care- 
fully examined  and  described  by  Dr.  J.  "W.  Williams  in  a  valuable  monograph 


Fig.  432. — Subperitone.m,  i'v>t  developed  entirely  from  the  Peritoneum. 
A  type  of  cyst  frequently  met  with  in  pelvic  inflammatory  cases.     Natural  size. 


upon  this  subject  (see  Trans,  of  the  Amer.  Gyn.  Soc,  vol.  xviii,  1893).  The- 
tumor  of  the  right  ovary  was  Y  X  6  X  5  centimeters  in  diameter,  weighed 
220  grammes,  and  was  like  ivory  in  consistence,  I  have  also  seen  a  calcified 
corpus  luteum  in  the  ovary  of  an  old  negress  on  the  dissecting  table ;  the 
little  mass  imbedded  in  the  ovary  was  spherical,  white,  about  1  centimeter  in 
diameter,  covered  with  little  short  spicules,  and  when  the  shell,  about  1  milli- 
meter thick,  was  broken,  the  interior  was  found  smooth  and  filled  with  a  watery" 
fluid. 

The  specimen  figured  in  the  text,  given  me  by  Dr.  G.  S.  Peck,  of  Youngs- 
town,  Ohio,  is  an  almond-shaped  ovarian  "  calculus,"  partly  enveloped  in  a  thin 
fibrous  capsule,  which  microscopically  consists  of  fibrillated  tissue  poor  in  nuclei 


FIBROID   TUMORS   OF   THE   OVARY. 


28T 


and  containing  calcareous  particles  scattered  through  it.     The  stone  itself  is  made 
up  of  chalklike  material,  which  Dr.  Aldrich  upon  analysis  found  to  contain  a 


.^_  _....^<fSS7?ij^^s:^iJUi^ti. 


e 


¥ 


Fig.   433. — The   Pedicle   of   the    Hydatid   (Appendix    Vesicularis,  Kossmann)  tied   about   the    Free 
Tubal  Fimbria  at  its  Base,  close  to  the  Tubo-ovariajt  Fold. 

The  white  thickened  fimbria  is  in  marked  contrast  to  the  normal  red  folds  above.    McGovern,  Auif.  23, 
1897.    Natural  size. 

large  amount  of  calcium  phosphate,  with  traces  of  the  oxalate  and  carbonate  of 
calcium,  together  with  traces  of  magnesium  phosphate  and  organic  matter. 


.Pedicle  of  t^ydatiol 


Ov.  fiinb.    (.fatly  degenerated) 


Wl     .  S^-i^-O  »A-*^        ^t 


Fio.  434. — Showing  the  1'ediole  of  the  Hydatid  tied  akoind  the  Fimbria,  enlarged;   showing  also 
THE  Appearance  of  the  White  Fatty  Degenerated  Fimbria. 

The  right-hand  figure  shows  the  adhesion  to  the  pedicle  and  the  knot.     Aug.  23, 1897. 


288 


OVARIOTOMY. 


The  entire  ovary  is  usually  involved,  and  the  large  tumor  preserves  the  form 
of  a  coarse  hypertrophy  of  the  ovary. 


Fig.  435. — Fibroid  Tumor  of  the  Ovary. 


Showin<j  the  coarse  enlarcrement  of  the  ovary,  with  numerous  sulci  and  vessels  coursing  over  the  surface 
from  tlie  hilum.     The  uterine  tube  and  mesosalpinx  are  seen  above.     No.  261.     Ys  natural  size. 

Microscopically,  ovarian  fibroids  appear  to  be  made  up  of  a  mass  of  connec- 
tive tissue  with  but  few  muscular  bundles  and  few  blood  vessels.    The  fibers  have 

no  regular  or  concentric  arrangement,  but 
are  interwoven  with  each  other  in  every 

"^..^^I^H  '^1^  In  twelve  hundred  abdominal  sections 

^iS^i^^HHf  SMst*'    iJir  ^  have  seen  four  cases — one  in  a  girl  of 

'^ijj^^Kr  iBlHil^r  twenty-two,  one  in  a  woman  of  forty-two, 

^^^^  ^K^BKr  another  in  a  woman  of  unknown  age,  and 

the  last  in  a  patient  fifty-nine  years  old. 

Loehlein  found  fibroid  ovaries  seven 
times  in  172  cases  of  ovarian  tumor; 
twice  they  were  bilateral. 

Ascites  is  usually  present 
and  forms  one  of  the  most  marked  characteristics  of  the  growth,  except  when  it 
is  small ;  it  was  present  in  all  of  my  cases  except  one,  where  the  tumor  was  only 
as  large  as  a  walnut. 


Fio.  430. — Calculus  of  the  Ovary,  seen  on 
ITS  Two  Surfaces.  Case  of  Dr.  G.  S. 
Feck.     Path.  No.  1790.     Natural  Size. 


FIBKOID   TUMORS   OF   THE    OVARY. 


289 


There  is  usually  no  pain  referable  to  the  tumor  itself,  although  when  large 
it  may  make  painful  pressure  on  the  surrounding  parts. 

The  growth  of  the  tumor  is  slow,  extending  over  years,  and  is  usually  con- 
fined to  one  side ;  the  average  size  is  that  of  one  or  two  fists.  Dr.  A.  Schach- 
ner,  of  Louisville,  operated  upon  one  weighing  fourteen  pounds,  in  a  colored 
woman  thirty-five  years  old  (A77ier.  Jour.  Ohs.,  vol.  xxix,  p.  377). 

The  patient  usually  applies  for  relief  either  because  she  has  discovered  a 
lump  in  the  abdomen  which  has  roused  her  fears,  or  because  she  is  burdened  by 
the  ascites. 

A  diagnosis  is  established  by  demonstrating  the  presence  of  a  hard  tu- 
mor in  the  pelvis,  attached  to  the  broad  ligament  and  accompanied  by  ascites, 
without  evidence  of  cachexia. 

The  small  tumor  figured  in  the  text  (G.  Y.,  San.  211,  May  21,  1897)  was  a 
fibroid  of  the  ovary,  of  almost  chalky  whiteness,  with  a  few  fine  vessels  on  its 


>>i 


4V 

J|      y# 

'7^, 

■Ty 

i 

/  ^ij*****^^ 

J 

1 

r'"  •  -^ 

%- 

(  '^ 

•    Fia.  437. — Partially  Calcified  Fibroma  of  the  Right  Ovary. 

The  tumor  springs  from  the  inner  border  and  is  chalky  white  and  dense,  with  a  few  vessels  distributed 
on  tlie  surface.  There  is  a  small  fibroma  of  the  utero-ovariau  ligament  wliich  is  detaclied  from  the  ovary. 
Viewed  from  behind.     Natural  size. 


surface,  and  subpyramidal  in  form ;  it  sprang  from  the  outer  end  of  the  ovary, 
and  was  associated  with  a  little  pediculated  fibroid  of  the  utero-ovarian  liga- 
ment, a  small  subserous  uterine  fibroid,  and  pelvic  inflammatory  disease.  Ute- 
rus, tubes,  and  ovaries  were  removed  by  an  abdominal  incision,  and  the  patient 
recovered. 


290 


OVAKIOTOMY. 


Sarcoma  of  the  Ovary. — The  sarcomata  are  amoiio;  the  rarest  of  all  the  ovarian 
tumors ;  the  diagnosis  "  sarcoma "  is  often  made  upon  a  purely  clinical  basis 
when  a  microscopic  examination  would  show  that  a  majority  of  these  tumors 
were  fibromata. 

The  sarcomata  consist  of  cells  closely  resembling  the  embryonic  connective 
tissue  and  are  subdivided  into  a  number  of  varieties  according  to  the  spe- 
cial character  of  the  cell ;  we  have  in  this  way  sarcomata  which  are  round- 
celled,  spindle-celled,  and  giant-celled.  Further  varieties  are  the  angio-sar- 
comata,  adeno-sarcomata,  and  carcino-sarcomata.  They  are  also  either  cystic 
or  solid. 

The  gross  appearance  of  a  sarcomatous  ovary,  like  a  fibroma,  may  resemble 
a  coarse  hyjjertrophy  of  the  normal  organ,  which  is  ovoid,  often  fiattened  and 
lobulated.     The   surface   is    usually  smooth,   whitish,   bluish,   or  flesh-colored, 


Fig.  438. — Angio-sarcom.\  or  the  Left  Ovary  with  Metastasis  into  the  Uterus. 


The  ovarian  tumor  on  the  left  side  is  intimately  adlierent  to  the  uterus,  and  made  up  of  fibers  running 
parallel  to  each  other.  The  uterus  is  thrice  enlarged,  and  its  walls  twice  the  normal  thickness  and  studded 
with  irretrular  lobulated  and  round  masses,  standing  out  prominently  and  of  a  waxy  appearance.  Portions 
of  the  unaffected  right  ovary  and  tube  can  he  seen  to  the  right  of  the  uterus.  July  7, 1894.  Path.  No.  372. 
3^  natural  size. 


often  traversed  by  large  veins,  and  adherent  to  all  the  surrounding  structures. 
The  softer  tumors  tend  to  break  up  and  bleed  freely  on  handling.  On  section, 
the  more  solid  tumors  appear  white  or  pink  or  yellow  from  fatty  degeneration  ; 
hemorrhagic  areas  are  also  often  seen.  The  softer  tumors  have  a  brainlike 
appearance  and  feel  elastic  or  springy,  and  small  cyst  cavities  are  often  found. 
In  the  case  of  a  child  twelve  years  old  the  brainlike  solid  elements  lay  at  the 
hilum,  and  the  capsule  of  the  ovary  was  hfted  up  from  this  by  an  accumulation 
of  fluid  which  escaped  into  the  abdominal  cavity  by  a  smalj:  opening. 


SARCOMA    OF    THE    OVARY.  291 

Microscopically,  the  spindle  cells  are  found  arranged  in  irregular  bundles 
extendino^  in  every  direction. 

In  the  angio-sarcomata  the  cells  are  arranged  concentrically  around  the  thin- 
walled  blood  vessels. 

Clinical  Characteristic  s , — Sarcomata  of  the  ovary,  like  sarcomata 
of  other  organs,  are  most  frequently  found  in  early  life.  J.  Bland  Sutton  has 
collected  twenty  cases  occurring  in  children  fifteen  years  of  age  and  younger ; 
the  youngest  case  that  I  have  seen  personally  I  have  just  referred  to  :  it  was  a 
cysto-sarcoma  in  a  gu'l  of  twelve,  who  died  of  a  recurrence  about  a  year  after 
operation. 

Out  of  one  hundred  ovarian  tumors  in  women  over  seventy  there  was  one 
sarcoma. 

In  a  collection  of  thirty-seven  cases  made  by  Olshausen,  five  were  under 
twenty,  nine  were  between  twenty  and  thirty,  eighteen  were  between  thirty  and 
forty,  and  four  between  fifty-eight  and  sixty-seven  years.  In  the  younger  pa- 
tients the  round-celled  form  predominates,  while  the  sj^indle -celled  becomes 
commoner  ^vith  advancing  age. 

The  tumor  is  chiefly  characterized"  by  its  rapidity  of  growth,  and  often  by 
the  presence  of  an  ascites. 

A  cystic  sarcoma  may  be  so  soft  that  it  ruptures  under  a  moderate  degree  of 
pressure  made  in  the  examination.  In  one  of  my  cases  an  extensive  hemorrhage 
took  place  from  such  a  rupture,  and  the  patient,  who  was  rapidly  bleeding  to 
death,  barely  escaped  with  her  life  by  a  prompt  operation  and  saline  infusion 
under  the  breasts.     (Mrs.  C,  Dec.  -1,  1897.) 

Metastases  are  distributed  through  the  veins  and  are  found  in  the  stomach, 
peritoneum,  pleura,  and  intestines,  while  the  tumor  spreads  rapidly  by  conti- 
nuity and  contiguity  of  tissue,  until  the  broad  ligament,  the  uterus,  and  the 
surrounding  parts  are  infiltrated.  Metastases  are  commonest  in  the  adeno- 
sarcomata,  and  least  frequent  in  the  spindle-celled  form.  Death  occurs  from 
exhaustion. 

The  case  figured  in  the  text  (L.  K.,  2894,  Fig.  -138)  is  an  angio-sarcoma  of 
the  left  ovary,  operated  upon  by  me  July  7,  1894  ;  the  imtient  was  forty-eight 
years  old  and  the  mother  of  two  children.  For  six  months  she  had  suffered  from 
a  grinding  pain  in  the  left  ovarian  region,  and  for  the  same  length  of  time  she 
noticed  a  mass  growing  in  the  lower  abdomen.  I  found  the  abdomen  much  en- 
larged  by  a  firm  bilobate  mass  and  the  superficial  veins  distended.  The  uterus 
appeared  to  be  continuous  with  the  mass  on  its  left  side. 

At  the  operation  the  tumor  was  found  so  adherent  to  the  pehnc  peritoneum 
that  it  could  not  be  completely  detached,  but  tore  out  in  peculiar  parallel  fibers. 
In  order  to  complete  the  operation  and  check  the  hemorrhage  it  was  neces- 
sary to  remove  tlie  mass  with  the  uterus  which  was  amputated  in  the  cervical 
portion. 

The  greatly  enlarged  uterus  was  invaded  by  continuity,  and  apparently  by 
metastases  forming  globular,  polypoid,  and  fingerlike  masses  of  a  raw-beef  color. 
The  ovary  formed  a  reniform  mass  IG  by  10*5  centimeters  (0-4  by  4-2  inches), 


292  OVARIOTOMY. 

adherent  on  its  concave  side  to  the  uterus  ;  it  was  made  up  of  a  series  of  light 
red  and  pale  fibei-s  looking  like  muscular  tissue  ;  in  the  center  of  each  fiber,  run- 
ning parallel  with  it,  a  blood  vessel  was  found  with  an  inner  lining  of  endothe- 
lium, and  in  places  a  delicate  muscular  coat,  immediately  surrounding  which  were 
eight  to  ten  lajers  of  spindle  cells  parallel  to  the  vessel ;  in  less  vascular  parts 
of  the  tumor  the  cells  did  not  show  any  definite  arrangement.  The  surface  of 
the  uterine  mucosa  was  intact  but  atrophic.  The  patient  recovered  from  the 
operation  and  died  some  months  later  of  a  continuance  of  the  growth,  which 
was  not  entirely  extirpated. 

Treatment  of  Ovarian  Tumors. — -The  proper  treatment  of  ovarian  tumors  is 
by  extirpation  as  soon  after  the  discovery  of  the  tumor  as  the  phj'sical  condition 
of  the  patient  will  permit. 

The  reason  for  an  early  interference  with  ovarian  growths  is  the  impossi- 
bility of  deciding  with  certainty  that  the  tumor  is  not  malignant,  and  still  so 
limited  in  its  extent  that  it  may  be  successfully  removed. 

I  recall  in  this  connection  the  case  of  a  healthy  active  young  woman  with  a 
little  ovarian  tumor  on  the  left  side  not  as  large  as  a  lemon ;  she  was  so  well  and 
had  such  a  horror  of  surgery  that  I  was  influenced  by  her  friends  to  say  nothing 
to  her  about  the  tumor,  under  the  proviso  that  she  would  remain  under  obser- 
vation. When  I  saw  her  a  year  later  the  pelvis  was  choked  by  papillomatous 
tumors,  and  with  an  imj)lantation  upon  the  peritoneum  beyond  the  reach  of  sur- 
gery, and  in  a  few  weeks  she  died. 

An  apparently  harmless  cyst  may  rupture  at  any  moment,  and  so  disseminate 
the  seeds  of  a  carcinoma  or  papilloma  over  the  peritoneum.  By  waiting,  the 
further  risk  is  incurred  of  torsion  of  the  pedicle  with  hemorrhage,  either  fatal 
or  so  great  as  to  compel  an  immediate  operation  under  unfavorable  circum- 
stances. 

With  delay,  also,  inflammatory  changes  may  supervene,  adhesions  may  fonn, 
and  the  cyst  itself  may  suppurate,  and  an  operation,  which  would  have  been 
short  and  simple  at  flrst,  is  transformed  into  a  protracted  one  embarrassed  by 
numerous  complications.  Furthermore,  with  delay  comes  exhaustion,  inter- 
ference with  the  excretory  functions  of  the  bowel  and  bladder,  the  risks  of 
hydroureter  from  pressure,  and  embarrassed  digestion,  respiration,  and  circu- 
lation. 

We  must  add  to  these  reasons  also  the  mental  anxiety  of  the  patient  who 
harbors  a  tumor,  as  well  as  the  physical  discomforts  which  must  continually  in- 
crease until  the  tumor  is  removed. 

All  of  these  cogent  reasons  for  performing  the  operation  at  an  early  date, 
together  with  the  removal  of  the  great  reason  for  postponement,  a  high  percent- 
age of  mortality,  justify  the  present  attitude  of  abdominal  surgeons  in  insisting 
that  there  shall  be  no  undue  delay  when  once  the  diagnosis  is  clearly  established. 

The  reasons  which  induced  the  patients  to  seek  relief  was  the  mere  presence 
of  a  tumor  in  forty-four  cases,  the  increasing  size  of  the  abdomen  in  twenty- 
seven  cases,  pain  in  twelve  cases,  edema,  dysj)nea,  and  tachycardia  in  four  cases, 
and  in  one  case  exhaustion  and  weakness. 


TREATMENT    OF    OVARIAX    TUMORS.  293 

Contra-indications  to  Operation  . — The  age  of  the  patient  does 
not,  as  one  would  suppose,  contribute  any  vaHd  reason  for  refusing  to  operate, 
for  out  of  one  hundred  women  who  were  over  seventy  years  of 
age,  operated  upon  by  fifty-nine  different  surgeons,  many  of  them  in  the  early 
evolutionary  years  of  aseptic  surgery,  only  twelve  died.  (See  0 c'ariotomy  in  the 
Aged,  by  H.  A.  Kelly  and  Mary  Sherwood.  Johns  Hopk.  Hosp.  Rep.,  vol.  iii, 
p.  509.) 

It  is  important  also  to  note  that  the  number  of  malignant  cases  which  tend 
to  affect  the  pennanency  of  the  result  in  this  group  was  surprisingly  small. 

The  classification  was  as  follows  : 

Nature  of  Tumor.                                                                                                No.  of  Cases. 

Multilocular  cyst 60 

Unilocular  cyst 12 

"Cyst" 7 

"  Tumor  " 9 

Parovarian  cyst 3 

Dermoid  cyst 2 

Tuberculous 1 

Sarcoma 1 

Fibroid 2 

Papilloma 3 

Total 100 

Remarkably  favorable  also  are  the  results  even  in  women  over  eighty 
years  of  age,  as  shown  by  the  collection  of  eleven  cases  made  by  T.  B. 
Sutton  {Surg.  Dis.  of  the  Ovaries,  etc.,  new  ed.,  1896,  p.  175);  in  the  hands  of 
ten  operators,  every  case  recovered. 

There  is  also  no  reason  for  deferring  operation  in  young  children,  but 
rather  many  cogent  reasons  for  removing  the  tumor  as  soon  as  practicable — 
in  the  rapidity  of  growth,  the  smaller  space  and  tense  walls,  and  the  increased 
liability  to  malignancy  (sarcoma). 

Out  of  100  cases  in  girls  fifteen  years  of  age  and  under,  collected  by  Sut- 
ton, in  the  hands  of  almost  as  many  different  operators,  there  were  -11  simple 
cysts  and  adenomata,  with  3  deaths ;  38  dermoids,  with  5  deaths ;  21  sarcomata, 
with  7  deaths. 

There  is  a  notable  difference  in  the  proportions  between  the  various  kinds 
of  tumors  in  this  table  and  that  of  the  old  women,  the  sarcomata  in  the  children 
forming  nearly  20  per  cent  of  the  Avhole,  while  but  one  case  of  sarcoma  is  re- 
corded in  old  women ;  in  the  children,  too,  there  is  a  relative  frequency  of 
dermoid  tumors,  38  to  100,  while  in  the  aged  the  ratio  is  but  2  to  100.  The 
increased  mortality  in  youth  is  due  to  the  sarcomata. 

The  good  or  the  ill  condition  of  the  patient  naturally  miH- 
tates  for  or  against  the  operation,  and  where  the  patient  is  much  reduced  or 
is  afflicted  with  any  chronic  disease  of  the  vital  organs,  her  chances  of  recovery 
are  not  so  good  ;  the  increased  danger,  however,  will  never  prevent  a  conscien- 
tious operator  from  taking  necessary  risks,  on  account  of  a  desire  to  protect  his 
statistical  tables. 


294  OVARIOTOMY. 

By  assiduous  attention,  witli  rest  in  bed  and  regulation  of  the  emunetories,  a 
patient  whose  vital  resources  seem  at  first  sight  depressed  below  the  safety  line 
may  often  be  lifted  up  above  it,  and  so  pass  through  her  oj)eration.  Heart 
disease,  except  in  its  advanced  form,  is  a  serious  disadvantage  only  in  pro- 
tracted, severe  opei-ations,  and  a  slight  albuminuria  and  casts  often  clear  up  at 
once  after  taking  away  the  tumor. 

An  uncertain  diagnosis  too  often  acts  to  deter  the  surgeon  from 
performing  an  operation,  especially  where  ascites  and  hard  masses  are  felt  in 
the  pelvis  or  in  the  abdomen  ;  it  is  in  just  this  class  of  cases  in  which  an  inex- 
jjerienced  operator  often  errs  and  in  which  the  most  experienced  may  occasion- 
ally make  a  wrong  diagnosis.  All  doubtful  cases  should  at  least  be  given  the 
benefit  of  an  exploratory  incision,  when  in  some  cases  the  disease  will  prove  not 
to  be  carcinoma  or  papilloma,  ])ut  tuberculosis,  and  some  malignant  cases  will 
be  found  capable  of  relief  by  colmplete  extirpation  of  the  growth. 

A  marked  advantage  will  also  be  gained  in  cases  in  which  the  disease  is  not 
eradicable  by  taking  out  the  mother  tumor  whenever  this  is  possible,  relieving 
the  pressure  of  the  ascites,  and  checking  the  rapidity  of  the  growth.  Complete 
and  permanent  recoveries  from  papilloma  already  distributed  over  the  perito- 
neum have  been  noted  under  these  circumstances. 

I  think  there  is  scarcely  an  operator  of  experience  who  has  not  been  sur- 
prised in  these  ways  a  number  of  times. 

I  have  dwelt  elsewhere  upon  the  minute  preliminary  investigation  of  the 
patient's  physical  condition  and  those  general  preparations  for  operation  which 
are  so  important  in  securing  a  good  result,  and  so  need  not  repeat  them  here 
(see  Chapter  XX j. 

Tapping  an  ovarian  cyst  is  no  longer  a  justifiable  operation,  either 
as  a  curative  measure  or  to  give  relief  so  as  to  be  able  to  postpone  the 
operation. 

It  is  true  that  in  rare  instances  a  parovarian  cyst  has  not  refilled  after  tap- 
ping, but  no  amount  of  diagnostic  precision  can  ever  assure  the  operator  that  in 
any  particular  instance  the  tumor  does  not  contain  papillary  elements  which  may 
soon  after  become  disseminated  over  the  peritoneum,  and  in  tapping  tumors  of 
other  kinds  these  risks  are  still  more  increased,  and  associated  with  them  are 
also  the  risks  of  wounding  a  lai'ge  blood  vessel  in  the  sac  wall  or  of  letting  out 
a  quantity  of  its  irritating  contents  to  excite  a  violent  peritonitis  and  add  enor- 
mously to  the  difficulties  of  the  subsequent  operation. 

There  is  but  one  class  of  cases  in  which  I  would  ever  use  the  trocar  to  reduce 
the  size  of  the  tumor  before  operation,  and  that  is  where  there  is  an  enormous 
tumor  with  widely  spreading  ribs  and  great  dyspnea.  A  great  advantage  is 
gained  here  if  the  abdomen  can  be  so  far  reduced  in  size,  two  or  three  days 
before  the  operation,  as  to  allow  the  respiratory  apparatus  and  the  circulation  to 
readjust  themselves,  to  some  extent,  to  the  new  conditions. 

The  aseptic  technique  which  controls  every  part  of  the  operation  is  fully 
described  in  Chapter  XX  on  the  general  principles  common  to  abdominal 
operations. 


TKEATMEXT    OF    OVARIAX    TUMOES.  295 

The  various  operations  may  be  considered  under  the  following 
heads : 

1.  A  median  abdominal  incision  exposing  the  tumor. 

2.  Evacuation  and  withdrawal  of  the  cjst. 

3.  Liberation  of  all  adhesioas. 

4.  Ligation  of  the  pedicle. 

5.  Intraligamentary  cysts. 

6.  Examination  of  the  opposite  ovary. 

7.  Cleansing  the  peritoneum  if  it  has  been  soiled  by  fluid  or  blood. 

8.  Closure  of  the  incision. 

The  patient  is  put  upon  a  table  arranged  for  the  elevation  of  the  pelvis,  and, 
if  the  tumor  is  a  prominent  one,  the  table  is  raised  but  slightly  or  not  at  all  until 
the  cyst  is  evacuated  of  its  contents,  when  it  is  elevated  just  enough  to  cause  the 
small  intestines  to  gravitate  up  above  the  upper  angle  of  the  incision. 

A  small  median  incision  is  first  made,  opening  the  abdomen,  at  a 
point  a  little  higher  up  than  in  operations  for  diseases  limited  to  the  pelvic 
cavity,  but  not  quite  so  high  as  in  the  case  of  large  myomatous  uteri.  Care 
must  be  taken,  in  picking  up  and  cutting  the  peritoneum,  not  to  cut  into  the 
tmnor  lying  in  contact  with  it. 

Evacuation  of  the  Cyst . — A  point  is  selected  opposite  to  the  in- 
cision which  is  free  from  large  vessels,  and  while  the  assistant  makes  a  gentle 
pressure,  keeping  the  abdominal  walls  applied  to  the  cyst  wall  on  both  sides  of 
the  incision,  the  operator  plunges  a  small  knife  into  the  cyst,  avoiding  vessels, 
and,  instantly  ^vithdrawing  it,  stops  the  opening  with  a  finger  before  any  of  the 
contents  have  had  time  to  escape.  He  then  takes  up  a  large  glass  trocar,  armed 
with  a  stiff  rubber  hose,  and  pushes  it  through  the  opening  into  the  cyst,  and  so 
discharges  its  contents.  As  soon  as  enough  fluid  has  escaped  to  make  the  cyst 
wall  flaccid,  it  is  caught  with  forceps  on  both  sides  and,  if  there  are  no  ad- 
hesions, dra-\vn  out  of  the  incision  over  to  one  side,  and  the  patient  is  turned 
over  a  little  so  as  to  facilitate  the  free  flow  of  the  fluid  without  risking  contami- 
nating the  peritoneum.  As  the  cyst  goes  on  collapsing  it  is  caught  by  succes- 
sive pairs  of  forceps  and  drawn  farther  and  farther  out  until  the  whole  of  it  is 
delivered  and  the  pedicle  lies  in  the  incision. 

In  the  case  of  an  ovarian  monocyst  or  a  parovarian  cyst,  this  may  often  be 
done  without  once  even  exposing  the  intestines  to  view. 

The  operator  should  carefully  avoid  soiling  his  hands  with  any  of  the  con- 
tents of  the  sac,  and  the  abdominal  wall  should  be  wiped  off  and  the  tumor  cov- 
ered with  gauze  while  the  pedicle  is  being  ligated. 

A  monocystic  ovary  or  an  ovary  with  two  larger  cysts  and  a  number  of  small 
ones  grouped  about  the  pedicle  may  be  easily  delivered  in  this  way  through  a 
small  incision,  but  when  the  tumor  contains  a  thick  pseudomucinous  secretion 
which  will  not  run,  and  when  it  is  made  up  of  a  conglomeration  of  small  cysts 
which  can  not  be  emptied  in  this  way,  it  will  be  necessary  to  insert  two  fingers 
to  lift  up  the  abdominal  wall  and  then  to  slit  it  up  and  down  until  the  opening 
is  large  enough  to  let  the  tumor  out  entire  by  its  small  diameter. 
61 


296 


OVARIOTOMY, 


In  the  case  of  a  generally  adherent  suppurating  cyst,  after  making  the  evacua- 
tion as  thorough  as  possible,  the  edges  of  the  puncture  opening  should  be  closed 
by  forceps,  and  as  fast  as  the  tumor  is  delivered  it  should  be  wrapped  in  folds 
of  gauze  to  limit  the  contamination  from  its  contents  as  much  as  possible.  For- 
tunately in  these  cases  the  micro-organisms  are  rarely  active,  otherwise  the  mor- 
tality would  be  much  higher  after  operation,  as  some  contamination  of  the 
peritoneum  is  often  unavoidable. 

A  parovarian  cyst  never  has  the  pearly  white  wall  of  an  ovarian  tumor,  and 
may  also  be  distinguished  at  sight  by  the  two  layers  of  blood  vessels  crossing 
each  other,  one  in  the  peritoneum  and  one  beneath  it  in  the  cyst  wall  prop- 
er ;  the  peritoneum  is  also 
^A"bdoniiiial  Incision     movable  over  the  cyst. 

When  the  tube  and  the 
mesosalpinx  are  spread  out 
over  such  a  cyst,  the  meso- 
salpinx with  its  large  ves- 
sels often  lies  directly  un- 
der the  incision,  and  it  is. 
well  in  such  a  case  to  try 
to  rotate  the  tumor  a  little 
or  to  draw  the  incision  to 
one  side,  or  to  puncture 
higher  up,  so  as  to  avoid  in- 
juring these  vessels.  When 
the  abdomen  is  filled  with 
an  ascites  this  can  usually 
be  recognized  just  before 
the  peritoneum  is  opened 
by  its  dark,  almost  black, 
color. 

If  the  tumor  is 
malignant,  a  papillo- 
ma, a  soft  sarcoma,  or  a 
carcinoma,  it  is  best  to 
make  a  long  incision,  so 
as  to  work  rapidly  with  the  utmost  freedom,  and  to  wrap  the  tumor  up,  as  soon 
as  it  can  be  grasped,  in  abundant  gauze,  and  so  handle  it  in  this  way. 

A  soft  sarcoma  or  a  papilloma  will  often  begin  to  break  down  and  bleed 
frightfully  as  soon  as  it  is  grasped  with  a  view  to  enucleation.  It  is  useless  in 
such  a  case  to  waste  valuable  time  trying  to  control  the  bleeding  vessels  in  the 
friable  tissue.  The  only  safe  plan  is  to  control  at  once  the  main  vessels  going  to 
the  tumor  by  applying  artery  forceps  to  the  broad  ligament  at  the  pelvic  brim, 
so  as  to  catch  the  ovarian  vessels,  and  one  or  two  pairs  at  the  uterine  cornu  to 
catch  the  uterine  vessels. 

In  order  to  get  at  the  broad  ligament  in  this  way  it  may  sometimes  be  neces- 


Periton.Tes. 


Vag. 

Fig.  439. — Monocystic  Tumor  of  the  Left  Broad  Ligament. 

Showintf  the  tube  displaced  and  spread  out  on  the  anterior  sur- 
face oftlie  tumor,  as  well  as  the  greatly  dilated  vessels  of  the  meso- 
salpinx below  the  tube.  There  is  also  a  myoma  in  the  anterior 
uterine  wall,  and  adhesions  to  the  opposite  tube  and  ovary.  The 
dotted  line  shows  the  part  of  the  tumor  opposite  the  abdominal  in- 
cision.    J^  natural  size. 


TKEATMEKT    OF    OVAKIAN    TL'MOKS. 


297 


sary  under  these  circumstances  to  drag  the  tumor  out  boldly  by  handfuls  in  the 
face  of  an  active  hemorrhage.  In  such  a  case  the  immediate  risk  to  hfe  over- 
balances any  remoter  consideration,  such  as  the  contamination  of  the  peritoneum 
with  the  tumor  elements.  After  an  evacuation  of  this  kind  the  abdomen  must 
be  most  carefully  washed  out  and  the  broad  ligament  in  the  bite  of  the  forceps 
cleansed,  lest  any  bit  of  the  tumor  be  left  behind. 

Liberation  of  Adhesions. — The  various  ways  of  dealing  with  adhe- 
sions are  similar  to  those  in  other  affections,  and  are  fully  dealt  with  in  the 

Mesenl.of  imall  int.aollito  cystwall. 
■  OtrisntuTii   adt^   Totyst. 


Fig.  440. — Suppceatino  Adhekent  Ovarian  Cvst. 

Showing  extensive  attachments  to  the  uterus,  bladder,  omentum,  small  intestine,  and  mesentery.    The 
bladder  and  the  uterus  arc  pulled  high  up  out  of  the  pelvis.     Jan.  20,  1897. 


chapter  on  Complications  Common  to  Abdominal  Operations.  I  will  here  only 
insist  upon  a  few  jjeculiarities  connected  with  this  group  of  tumors.  The  adhe- 
sions to  the  abdominal  wall  which  sometimes  take  in  the  whole  anterior  parietes 
must  1)6  detached  with  deliberate  care  to  avoid  dissecting  off  the  peritoneum 
with  the  ovarian  sac.  Such  a  faulty  dissection  is  usuall}'  begun  at  the  incision 
by  starting  in  the  wrong  plane  of  tissues,  and  it  may  then  be  continued  outward 
until,  as  I  have  seen  done,  nearly  the  whole  anterior  parietal  peritoneum  is  de- 


298 


OVARIOTOMY. 


tached  from  its  cellular  base.  All  ordinary  adhesions  can  usually  be  separated 
by  pushing  the  hand  with  open  lingers  in  between  the  sac  wall  and  the  perito- 
neum, and  oj^ening  and 
closing  the  fingers  with 
a  shearing  motion.  Any 
particularly  dense  adhe- 
sions are  best  dealt  with 
by  leaving  a  portion  of 
the  outer  fibrous  layer  of 
the  sac  adhering  to  the 
abdominal  wall.  Omen- 
tal adhesions,  if  exten- 
sive and  dense,  may  be 
treated  by  sacrificing  the 
entire  omentum  up  to  the 
transverse  colon. 

The  general  principle 
of  treating  intestinal  ad- 
hesions is  in  all  cases  to 
avoid  opening  the  lumen 
of  the  bowel,  and  this 
may  best  be  done  by  cut- 
ting through  the  outer 
coat  of  the  sac  and  then 
stripping  this  coat  off 
from  the  rest  and  leaving  it  adherent  to  the  bowel  as  a  protection  from  the  injury 
which  would  otherwise  be  inevitably  inflicted  in  attempting  a  complete  detach- 
ment of  the  entire  tumor.  This  principle  may  be  carried  out  whether  the  adhe- 
sion is  small  or  large,  and  is  of  most  avail  in  enu- 
cleating densely  adherent  suppurating  ovarian  cysts. 
Such  a  case  (E.  B.  L.,  4946,  Jan.  20,  1897),  ex- 
tremely complicated,  is  figured  in  the  text,  where 
a  suppurating  ovarian  cyst  filled  the  pelvis  and  the 
lower  abdomen  and  was  universally  adherent ;  the 
ilium  from  the  ileo-cecal  valve  across  to  the  left 
side  was  flattened  out  over  the  top  of  the  tumor, 
which  also  adhered  to  its  mesentery  and  over  the 
vertebral  column  and  the  great  abdominal  vessels. 
A  complete  separation  could  not  be  effected  here 
without  resecting  the  ilium ;  the  complication  was 
met  by  leaving  a  cap,  consisting  of  the  outer  fibrous 
coat  of  the  tumor,  adhering  to  this  entire  area. 
The  recovery  was  uneventful. 

Ligation  of  the    Pedicle. — Gauze  is  placed  under  and  around  the 
pedicle  while  it  is  held  up,  and  two  or  three  or  more  fine  silk  ligatures  are  passed 


Fig.  441. — Suppurating  Adherent  Ovarian  Cyst. 

Showing  the  relations  of  that  part  of  the  cyst  wall  which  is  inti- 
mately attached  to  the  small  intestine  and  the  mesentery.  Jan.  20, 
1897. 


Fig.  442. — Cross-.section  of  the 
Intestinal  and  Mesenteric  At- 
tachment. 

Showing  the  two  layers  in  the 
cyst  wall ;  the  inner  layer  was 
stripped  off,  leaving  the  outer. 
Jan.  20,  1897. 


TREATMENT  OF  OVARIAX  TUMORS. 


299 


Periton. 


V|'^'       Myoma 


"*• ; 


^ 


Fig.  443. — Diagram  feom  a  Case  of  Intraligamextary  Ctst,  seex  from  Above. 

Showing  the  relations  of  the  separated  peritoneal  layers  of  the  left  broad  ligament  to  the  cyst,  and  the 
uterine  tube  (FT)  spread  out  on  its  surface.  The  right  ovary  and  tube  are  adherent,  the  tube  is  attached  to 
the  cyst.     Jan.  5,  1894. 


•..,  Ov.  vessels 


.J' 


Fig.  444. — Diagram  showing  the  Manner  of  closing  up  the  Deficit  left  by  the  Enucleation  of 
an  Intralioamentary  Cyst  by  a  Continuous  Catgut  Suture  from  Pelvic  Wall  to  Uterine 
CoRNu.    Jan.  5, 1894. 


800 


OVARIOTOMY. 


through  the  clear  spaces  so  as  to  inchide  the  vessels  which  are  usually  grouped 
at  either  border.  These  should  be  placed  well  off  from  the  tumor  so  as  to  allow 
plenty  of  room  to  cut  the  tumor  away  without  shaving  it  too  closely.  The 
utero-ovarian  ligament  should  be  ligated  separately. 


^-^ 


Fig.  445.— Intraligajientakt  Graafian  Follicle  Cysts,  seen  in  situ.     Nov.  24,  1804. 

In  a  young  woman  it  is  not  necessary  to  remove  the  uterine  tube  unless  it 
is  spread  out  over  the  surface  of  the  tumor.  It  is  a  good  plan  to  burn  the 
pedicle  off  with  a  thermo-cautery  so  as  to  avoid  leaving  a  raw  space  behind  ;  the 
burnt  pedicle  is  much  less  liable  to  contract  post- operative  adhesions  with  the 
contiguous  structures. 

Dr.  Skene,  of  Brooklyn,  has  devised  an  electro-cautery  which  mummifies  the 
stump  so  that  hemorrhage  can  not  take  place,  and  there  is  no  need  of  using  a 
ligature. 

Intraligamentary  Cysts. — When  the  ovarian  tumor  grows  partly 
free  into  the  abdominal  cavity  and  partly  down  between  the  layers  of  the  broad 
ligament,  there  is  no  real  pedicle,  but  the  separation  may  often  be  easily  effected, 
after  ligating  the  vessels  on  the  side  of  the  pelvic  brim  and  on  the  uterine  side, 


TREATMENT  OF  OVARIAX  TUMORS. 


301 


l)y  splitting  the  peritoneum  on  a  line  at  a  level  with  the  pelvic  brim  and  then 
simply  drawing  or  shelling  the  tumor  out  of  the  loose  cellular  attachments  which 
still  hold  it  in  the  peh*is.  These  investing  tissues  are,  as  a  rule,  not  vascular, 
and  ligatures  may  be  generally  dispensed  with.  The  top  of  the  broad  hgament 
is  then  closed  in  by  a  continuous  catgut  suture  (see  Figs.  443  and  444). 

When  the  entire  mass  lies  beneath  the  peritoneum  the  enucleation  is  more 
difficult  and  the  difficulties  increase  in  direct  ratio  with  the  size  of  the  tumor. 

On  opening  the  abdomen  in  the  case  of  a  large  retroperitoneal  tumor,  the 
posterior  and  the  visceral  layers  of  the  peritoneum  may  be  found  lying  in  direct 
contact  with  the  anterior  wall,  the  pelvic  peritoneum  is  lifted  up,  the  rectum  is 
displaced,  and  the  sigmoid  or  the  colon  pushed  forward.  The  ureter  is  usually 
behind  the  growth,  and  if  injured,  the  injury  comes  from  detaching  it  from  an 
adherent  tumor. 

The  uterus  is  displaced  by  an  intraligamentary  tumor  toward  the  opposite 
side,  or  if  there  are  intraligamentary  tumors  on  both  sides,  it  is  crowded  between 
them  into  the  front  part  of  the  pelvis. 


Fio.  440. — Inthaliuamentary  Graafian  Follicle  Cysts.     Nov.  24.  1S94. 

If  both  sides  are  affected,  it  will  be  easier  and  better  to  operate  by  removing 
the  uterus  and  tumors  together,  by  Hgating  the  ovarian  vessels  first  on  one  side, 
and  so  opening  up  the  broad  ligament  and  peeling  out  and  rolling  one  of  the 


303 


OVAEIOTOMY. 


tumors  with,  the  uterus  up  and  out  of  the  incision,  and  controlling  the  uterine 
vessels  of  that  side.     The  uterus  is  then  amputated  in  its  cervical  portion,  the 


Fig.  447. — Multiple   Dermoid  Cysts  of  Both  Ovaries,  with   Extensive   Pelvi-peritonitis   involving 
Uterus,  Tubes,  and  Ovaries,  seen  from  Above  and  Anteriorly. 

FU  is  the  fundus  uteri.  The  left  ovary  consists  of  a  number  of  cysts  (D,  Z>,  I))  covered  with  adhesions. 
The  left  tube  was  rigid,  and  distended  with  pus.  The  right  ovary  (D)  is  also  covered  with  adhesions;  and 
the  right  tube  has  been  amputated  by  bands  of  adhesions,  so  that  it  consists  of  three  separate  portions. 
Feb.  2,  1895.     Vs  ""tural  size. 

uterine  vessels  of  the  opposite  side  controlled,  and  the  second  tumor  shelled 
out  easily  from  below  upward ;  the  ovarian  vessels  are  then  clamj)ed  and  the 


Fig.  448.— Left  Dermoid  Cyst  and  Eight  Multilocular  Ovarian  Cyst  with  Twisted  Pedicle. 
Elevation  of  the  uterus.    No.  2766. 


TREATMENT   OF    OVARIAN   TUMORS. 


303 


whole  mass  removed,  following,  in  general,  the  technique  used  in  hystero-myo- 
mectomy. 

In  removing  an  intraligamentary  tumor  of  one  side,  it  is  important  to  bear 
in  mind  that  its  blood  supply  continues  to  be  derived  from  the  same  channels 
from  which  it  came  while  the  tumor  was  still  small — that  is  to  say,  the  ovarian 
and  the  terminal  branches  of  the  uterine  vessels ;  and  if  these  are  patiently 
sought  out  and  secured  at  once,  there  need  be  but  little  hemorrhage  throughout 
the  operation. 

If  the  tumor  is  cystic  and  is  made  up  of  one  or  two  larger  cysts,  the 
evacuation  of  the  fluid  will  give  the  operator  more  room  for  his 
manipulations  and  the  collapsed  sac  can  be  pulled  on  with  greater  advantage  in 
drawuig  the  tumor  out. 

In  shelling  out  intralig-  — =-_^o 

amentary  tumors  it  is 
best  to  avoid  using  the 
naked  fingers,  using  in 
their  stead  a  firm  sponge 
on  a  handle,  with  rubber 
finger  stalls  covering  the 
finger  tips. 

After  such  a  tumor  is 
removed  the  floor  of  the 
pelvis  is  laid  bare,  and  it 
is  a  wise  and  comforting 
plan  always  to  inspect 
the  ureter  throughout  its 
pelvic  course,  so  as  to 
be  perfectly  sure  of  its 
integrity. 

Complicated 
Cases . — In  cases  com- 
plicated by  disease  of 
both  ovaries,  as  in  the 
case  of  multiple  der- 
moids shown  in  the  text 
(Fig.  447),  or  where  a 
dermoid  of  one  side  com- 
plicates an  ovarian  cyst 
of  the  other  (Fig.  448), 
or  where  there  is  an  ex- 
tensive fibroid  degeneration  of  the  uterus  (Fig.  449)  associated  with  a  fibroid 
ovary,  it  is  better  to  do  a  hysterectomy  with  an  ovariotomy,  removing  the  uterus, 
tubes,  and  ovaries  in  one  mass  as  described  above. 

The  Opposite  Ovary . — The  opposite  ovary  ought  always  to  be  in- 
spected and  a  note  as  to  its  condition  entered  in  the  history.     If  it  is  evidently 


Fig.  440. — Fibroma   of  the   Left  Ovary  {MO),  with   Large  Myo- 

ilATA    (J/,  M)    OF   THE    UtERUS    (  U). 

Note  the  smooth  surface  and  coarse  exaggeration  of  the  fonii  of  the 
ovary,  the  large  vessels  and  the  dense  band  of  adhesion  {P")  stretch- 
ing down  under  its  hilum,  attaching  it  to  the  broad  ligament.  Jan. 
30,  1895.     y^  natural  size. 


304  OVARIOTOMY. 

diseased  it  should  be  removed,  too;  in  a  yoimg  woman  conservatism  should 
always  be  the  ruling  principle,  and  whenever  it  may  be  safely  applied,  a  tube  or 
a  sound  piece  of  ovary  should  be  retained,  even  if  it  be  but  one  tube  and  the 
opposed  ovary.  Kesection  of  the  ovary  may  be  practiced  in  the  case  of  der- 
moid cysts,  and  where  there  is  an  ovarian  cystoma,  like  that  shown  in  Fig.  406,  it 
would  be  perfectly  proper,  if  the  patient  was  a  young  woman,  and  it  was  neces- 
sary to  remove  the  opposite  ovary,  to  resect  the  one  affected  with  the  cystoma, 
leaving  the  portion  which  appeared  macroscopically  sound,  provided  the  patient 
consented  to  remain  under  observation  for  several  years   (see  Chapter  XXY). 

The  methods  of  cleansing  the  peritoneum,  the  question  of  drainage,  and  the 
closure  of  the  incision  are  discussed  in  other  chapters. 


Fig.  450. — Adeno-carcinoma  of  the  Cervix  with  Hydrodreter  of  Both  Sides. 

The  disease  stops  above  abruptly  at  the  junction  of  the  body  with  the  cervix  ;  below,  it  extends  well  out 
into  the  vaginal  vault  and  the  right  broad  ligament,  and  involves  the  entire  thicliness  of  the  cervix.  The 
right  ureter,  seen  cut  across,  is  converted  into  a  large  hydroureter.  On  the  left  side  two  ureters  are  seen, 
which  were  also  converted  into  hydroureters  of  lesser  degree.    Autopsy,  June  22, 1896. 


CHAPTEE   XXX. 

ABDOMINAL   HYSTERECTOMY   FOR  CARCINOMA   AND   SARCOMA   OF 

THE   UTERUS. 

1.  Causes. 

2.  Epithelioma  of  the  cervix.     Three  stages:   1.  Induration.     2.  Sloughing.    3.  Disappearance. 

4.  Mode  of  extension. 

3.  Adeno-carcinoma  of  the  cervix. 

4.  Adeno-carcinoma  of  the  body  of  the  uterus. 

5.  Cancer  of  the  uterus  with  myoma  or  tuberculosis. 

6.  Symptoms. 

7.  Diagnosis:   1.  From  subjective  symptoms.     2.  From  touch  and  inspection.     3.  From  micro- 

scopic examination  of  scrapings. 

8.  Treatment :    1.  Prevention — rules  for.     2.  Manner  of   examining  for  cancer.     3.  The   radical 

operation,     a.  Preparatory  treatment,     b.  Technique,    c.  Steps  in  the  operation. 

9.  Sarcoma  of  the  uterus. 

Caxcee  of  the  litems  is  a  malignant  disease  cliaracterized  by  an  atypical  pro- 
liferation of  the  epithelial  elements.  It  is  one  of  the  common  causes  of  death 
among  women  ;  according  to  a  computation  of  W.  R.  Williams,  made  in  1896, 
at  least  eight  thousand  women  were  suffering  from  cancer  of  the  uterus  in  Eng- 
land and  Wales  at  the  date  of  writing. 

Age. — In  fifty -two  of  my  cases  of  epithelioma  of  the  cervix  the 
following  ages  were  noted  : 

Between  31  and  35  years 5  cases. 

35  "  40  '  "  7  " 

40  "  45     "  19  " 

45  "  50     " 6  " 

50  "  55     "  7  " 

55  "  60     "  4  " 

60  '•  62     "  4  " 

Total 52  cases. 

It  is  clear  from  this  table  that  epithelioma  of  the  cervix  is  most  connnon 
near  the  menopause,  and  this  induction  coincides  with  the  experience  of  most 
investigators. 

In  thirteen  of  my  cases  of  adeno-carcinoma  of  the  cervix  the 
ages  were  : 

Between  30  and  35  years 2  cases. 

35  "  40  "    2      " 

"        40  "  45  "    1  case. 

"        45  "  50  " 4  cases. 

50  "  55  "     1  case. 

55  "  60  "    0      " 

*'        60  "  65  "    2  cases. 

"        65  "  70  "    1  case. 

The  commonest  period  of  occurrence  was  between  45  and  50. 

305 


306  ABDOMIXAL   HYSTERECTOMY   FOR   CARCINOMA    OF   THE    UTERUS. 

In  estimating  the  age  of  patients  with  adeno-carcinoma  of  the 
body,  some  allowance  must  be  made,  as  it  is  impossible  to  determine  with  ac- 
curacy just  when  the  disease  commenced.  In  thirteen  cases  the  patients'  ages 
were  as  follows : 

30  years 1  case. 

Between  35  and  40      "     1     " 

40    "     50      "     1     " 

"        50    "    55      " 5  cases. 

55    "     60      "     3     " 

60    "    65      "     2     " 

Total 13  cases. 

The  period  of  most  frequency  was  between  fifty  and  sixty.  The  average 
adeno-carcinoma  of  the  body,  therefore,  occurs  (or  perhaps  it  would  be  better  to 
say  makes  itself  evident)  at  a  later  period  than  either  epithelioma  or  adeno- 
carcinoma of  the  cervix. 

Causes. — The  etiology  of  cancer  is  obscure ;  it  has,  howevei*,  been  shown  that 
there  is  a  direct  causal  relation  l)etween  cancer  of  the  cervix  and  the  traumatisms 
of  childbirth.  Cancer  of  the  ceiwix  in  unmarried  and  nuUiparous  women  is  ex- 
tremely rare. 

In  fifty  of  the  cases  of  epithelioma  of  the  cervix  with  accurate  data  as  to 
marriage  and  the  number  of  pregnancies,  in  every  instance  the  pa- 
tient was  married,  forty-nine  out  of  the  fifty  had  borne 
children,  and  at  least  half  of  the  patients  had  had  five  or  more  children. 

Twelve  of  the  thirteen  patients  suffering  with  adeno-carcinoma  of  the  cervix 
had  been  pregnant.  The  thirteenth  was  unmarried,  and  gave  no  history  of 
impregnation. 

In  eleven  cases  of  adeno-carcinoma  of  the  body  it  was  found  that  ten  were 
married  and  one  single.  From  the  accompanying  tabulation  it  will  be  seen 
that  four  of  them,  although  married  for  many  years,  had  never  been  pregnant. 
In  no  case  did  a  woman  have  more  than  four  children. 

Para.  Mis. 

A.  married    7  years 0  0 

D.        "        12      "    0  0 

A.        "        21      "    1  0 

G.  single  0  0 

M.  married  24      "    2  0 

A.        "       33      '•    2  5 

G.        "       —     "    4  0 

A.        "       32      "    0  0 

P.        "       12      '•    1  0 

S.  0  1 

P.        "       31      "    0  0 

I  recall  only  three  cases  of  cancer  of  the  cervix  in  nulliparous  women  in 
my  entire  experience,  and  in  one  of  these  the  cervix  had  been  forcibly  dilated. 
Dr.  T.  A.  Emmet  told  me  that  the  only  case  of  cancer  of  the  cervix  he  had 
ever  seen  in  a  nullipara  was  also  one  where  forcible  dilatation  had  been 
practised. 


CAUSES. 


307 


From  a  histological  standpoint  the  parasitic  origin  of  the  disease  has  been 
repeatedly  asserted,  but  this  is  unjDroven ;  indeed,  many  of  these  so-called  para- 
sites have  been  found  to  be  nothing  more  than  degenerative  forms  of  epithelial 
cells.  It  has  been  repeatedly  asserted  that  there  exists  a  remarkable  racial  dif- 
ference between  the  negroes  and  the  whites  in  respect  to  the  liability  to  cancer, 
and  the  statement  has  even  been  made  that  the  negro  is  practically  immune. 
This  is  clearly  erroneous  according  to  my  statistics,  which  show  a  proportion  of 
eight  negresses  to  ninety-one  white  women. 

Cancer  or  carcinoma  of  the  uterus  begins  to  grow  primarily  either  in  or  on 
the  cervix  or  in  the  body  of  the  organ.  This  distinction  between  cancer  of  the 
cervix  and  of  the  body  can 
always  be  clearly  made  with 
the  naked  eye  in  the  early 
stages  of  the  disease,  and 
even  remains  clear  in  the 
most  advanced  stages  in  the 
majority  of  cases ;  occasion- 
ally, however,  in  the  latest 
stages,  the  body  is  affect- 
ed in  cervical  cancer,  and, 
what  is  rarer,  the  cervix 
becomes  affected  in  cancer 
of  the  body. 

There  are  three  varie- 
ties of  cancer  found  in  the 
uterus,  each  one  depend- 
ing upon  the  special  form 
of  epithelium  involved  in 
forming  the  growth.  The 
vaginal  portion  of  the  cer- 
vix is  covered  by  squa- 
mous epithelium,  and 
from  this  springs  first  the 
epithelioma,  the  squamous, 
or  flat-celled  variety  of  car- 
cinoma, which  preserves 
this  type  of  growth  through- 
out its  entire  history  and 
through  all  its  extensions, 
whatever  part  of  the  body 
it  may  invade ;  secondly, 
the  cervical  canal  and  the 
cer^^[cal  glands  are  lined  by 

one  layer  of  v  e  r  y  high  cylindrical  e  p  i  t  h  e  1  i  u  m  from  which  arise  the 
adeno-carcinomata  of  the  cervix,  as  the  name  indicates,  cancers  which  preserve 


Fio.  451. — t  1    nil    I  i.uvix. 

No  carcinomatous  tissue  oiiu  bu  seen  at  tlie  vajcrinal  vault,  and 
the  vafrinal  tissue  has  a  normal  appearance,  but  the  carcinoiuatous 
infiltration  has  extended  like  a  plate  of  cartila^'e  beneath  tiie  vajrina 
over  the  area  included  within  the  dotted  lines.  Dec.  'J,  Is'JO.  Nat- 
ural size. 


308 


ABDOMINAL   HYSTERECTOMY    FOR   CARCINOMA    OF   THE    UTERUS. 


in  their  structure,  wherever  they  penetrate,  the  glandular  type ;  thirdly,  the 
uterine  mucous  membrane  and  its  glands  are  lined  by  a  single  layer  of  cylin- 
drical ciliated  epithelium;  this  gives  rise  to  the  adeno-carcinomata  of 
the  body  of  the  uterus. 

Epithelioma  of  the  Cervix. — The  clinical  picture  of  cancer  of  the  uterus 
varies  greatly  both  with  the  location  of  the  disease  and  with  the  stage  of  ad- 
vancement. 

Epithelioma  of  the  vaginal  portion  of  the  cervix  may  be  conveniently  di- 
vided into  three  stages  ;  in  the  earliest  of  these  the  cervix  shows  an  area  of 
induration  and  infiltration  with  increased  vascularity  and  a  glazed 
appearance,  or  the  tissue  may  present  a  slight  granular  appearance  due  to  small 
fingerlike  projections.  The  diseased  tissue  may  begin  to  break  down  soon  and 
present  an  excavated  area,  or  it  may  go  on  until  both  lips  of  the  cervix  are 
involved  and  a  mass  is  formed  which  fills  the  whole  vagina,  and  appears  to  be 
attached  to  the  vault  by  a  pedicle,  closely  simulating  a  pedunculated  myoma. 
The  commoner  appearance,  however,  is  that  of  a  cauliflower  growth  with  numer- 
ous fissures  and  excrescences,  as  described  by  Clark  in  1824. 


Fio.  452. — Extensive  Epithelioma  of  the  Cervix  extending  up  toward  the  Fundus,  the  Upper  Part 
OF  WHICH  IS  Free.  Four  Phlebolitiis  in  the  Left  Broad  Ligament.  Bunches  of  Vesicles  on 
the  Dorsum  of  the  Right  Tube.     Gyn.  Path.  No.  625.     ^|^  Natural  Size. 

In  the  second  stage  the  growth  breaks  down,  bits  of  tissue  slough 
off,  and  a  portion  of  the  cervix  may  be  wanting,  leaving  an  excavated  ulcer 
with  infiltrated  edges. 

With  further  advance  in  the  third  stage,  the  entire  cer\dx  disap- 
pears, leaving  in  its  place  a  craterous  cavity  in  the  vaginal  vault  covered  by 
necrotic  material  with  hard,  irregular  walls.  With  this  extension  the  disease 
may  open  up  the  bladder,  the  rectum,  or  the  peritoneal  cavity,  although  in  the 
case  of  the  peritoneum  the  general  cavity  is  almost  invariably  shut  off  by  a 
plastic  peritonitis. 

Beginning  with  the  earliest  stages  of  the  disease,  the  cancer  cells  may  invade 
the  lymphatics,  traveling  as  far  as  the  glands,  which  then  enlarge  and  in  turn 
become  foci  for  further  extension.  I  am,  however,  convinced,  on  the  basis  of 
the  thorough  investigations  of  all  \nj  cases  by  my  associate  Dr.  T.  S.  Cullen, 


PLATE  XVII, 


X  ') 


i 


f 


-# 

# 


/ 


Fig.l, 


X  80 


Fig  2 


.\  <^( ) 


Ki.g.3 


MRrodel.fec 


Heliotype  Pnnung  Ctt,  boston 


1^ 


T^F^CK 


/^ent  va- 


epitheiiom 


PLATE  XV! : 


Y  Mr> 


X^O 


M  Bro'  ■ 


m'.'.o^yUi! 


DESCRIPTION  OF  PLATE  XVII. 

Fig.  1  is  from  a  case  of  epithelioma  of  the  cervix.  The  section  includes  a  portion 
of  the  cervix  and  adjacent  vaginal  mucosa.  Both  the  cervical  and  vaginal  mucosa 
show  marked  thickening,  but  there  is  no  tendency  on  the  part  of  the  epithelium  to 
penetrate  into  the  underlying  stroma. 

Fig.  2  is  a  section  through  the  thickened  vaginal  mucosa.  Note  that  the  papillae 
are  much  longer  than  usual,  and  that  the  epithelium  is  about  four  times  its  usual 
thickness. 

Fig.  3  represents  the  normal  vaginal  mucosa  as  found  a  short  distance  from  the 
thickened  mucosa. 

This  thickening  is  undoubtedly  due  to  a  gradual  extension  of  the  epithelioma,  but 
from  the  section  here  shown  one  would  not  be  justified  in  rendering  a  diagnosis  of 
epithelioma. 


.II Tx  aTAJ«i  '^o  T-oTTiiaofeaa 

noiJ'ioq  h  8»buIoni  aoiiosz  ailT     .xivisoyj..  .-.  .,..;'  'f-^'f*!''^"^  >o  eaao  e  moii.    .  ^    ::;,  i 
fi809x/flT  Ifini'gBY  bftfi  IboIvt^o  9iii  rfio3     .saoourn  1  i30jii,i),B  biiB  xr7n9r>  stU  ^o 

oJ  tauil'^diiqe  axfi  to  Jtaq  srfi  no  irouabnei  on  ar  oi'mij  juu  ,^fTiu93{oirf,1  f  'oda 

.     TIJoT     JilOif,;    <'<     ntilif'xflirCi  '     if'OI/Xn    8'tB 

i.aooirm  b^ae^oidi 

li.'U  ,j.  i  1  •)ilj  111  iioj3i:-»jy.a  L;jiLi;-fy  a  oj  ojjij  •^Ib'^Jdn.ouiiii  ^i  gaiasjioiilt  aiifT 

}o  ^h'  :§/ih9bno^  ni  boftitg/ir.  yd  to«  bluow  oao  nwode  Q'larf  nofJosis  sifi  raoil 


EPITHELIOilA    OF   THE    CERVIX. 


309 


that  the  frequency  of  this  lymphatic  involvement  in  the  earlier  stages  of  the 
disease  has  been  undulv  exaggerated. 

The  glands  which  receive  the  lymph  vessels  from  the  cervix  are  the  iliac 
group,  situated  at  the  pelvic  brim  just  at  the  bifurcation  of  the  iliac  vessels.  In 
only  one  of  the  oper- 
able cases  of  epitheli- 
oma where  the  glands 
have  been  examined 
have  I  found  the  sec- 
ondary growth,  and  in 
only  three  of  the  cases 
coming  to  autopsy,  and 
where  the  disease  was 
widespread,  were  these 
glands  the  seat  of  me- 
tastases. 

The  common  mode 
of  extension  of  the 
disease  is  by  the  con- 
tinuity of  tissue,  and 
the  extension  is  most 
rapid  in  those  direc- 
tions in  which  the  loose 
meshes  of  the  tissue 
offer  the  least  resist- 
ance ;  the  earliest  and 
most  marked  evidences 
of  the  extension  are 
therefore  found  at  the 
bases  of  the  broad  lig- 
aments, around  the 
vaginal  vault,  in  the 
connective  tissue  in- 
cluded in  the  utero-sacral  ligaments,  and  forward  and  downward  under  the  blad- 
der.  The  progress  of  the  disease  is  often  arrested  at  the  internal  o  s  uteri, 
and  the  involvement  of  the  body  of  the  uterus  is  rarely  found  in  epithelioma 
in  the  early  stages ;  toward  the  end  of  the  disease,  however,  the  body  is  fre- 
quently involved.  On  section,  the  growth  is  yellowish  white  and  waxy,  has 
sharp  irregular  margins,  and  stands  out  in  striking  contrast  to  the  surrounding 
sound  tissue.  On  close  examination,  the  cut  surface  is  made  uj)  of  a  network 
of  glistening  filjers,  enclosing  spaces  from  a  pin  point  to  3  millimeters  in  diame- 
ter, which  contain  frial)le  material  with  a  yellowish  tinge ;  these  are  the  cancer 
nests. 

Histologically  the  appearances  are  identical  with  those  found  in  the  scrapings 
removed  for  diagnosis  (see  A^ol.  I,  Chapter  XIV,  p.  493).     There  is  an  ingrowtli 


Fig.  453. — Inoperable  Epithelioma  of  the  Cervix,  in  which  the  Chief 
Involvement  is  at  the  Internal  Os,  where  the  Ltekis  is  Per- 
forated. 

In  the  mucous  membrane  of  the  fundus  a  few  epitlielial  nests  were 
found  lyinff  between  normal  uterine  glands.  Gyn.  Path.  No.  192,  March, 
1894:.     Natural  size. 


310 


ABDOMINAL   HYSTERECTOMY    FOR    CARCIXOMA    OF   THE    UTERUS. 


as  well  as  an  outgrowth  of  the  squamous  epithelium,  with  epithelial  prolonga- 
tions penetrating  the  stroma  of  the  cervix  in  all  directions. 

Adeno-carcinoma  of  the  Cervix. — Adeno-carcinoma  of  the  cervix  originates  in 
the  glandular  tissue  at  some  point  within  the  external  os ;  in  the  early  stages, 
on  laying  open  the  cervix,  a  nodular  growth  is  seen  involving  a  part  or  all  of 
the  cervical  canal  and  extending  down  to  the  external  os,  which  may  show  no 
evidence  of  disease. 

Later  in  the  disease  that  part  which  lies  nearest  the  surface  breaks  down  and 
forms  a  small  ragged  cavity  whose  walls  are  made  up  of  fine  fleshy  papillae. 
The  solid  part  of  the  growth  is  yellowish  white  and  is  sharply  defined  from  the 
normal  tissue  surrounding  it. 

When  the  growth  begins  near  the  external  os,  this  is  soon  involved,  so  that 
it  becomes  impossible  at  a  later  stage  to  differentiate,  from  the  macroscopic 
appearances,  between  this  and  the  epithehoma  just  described.  The  endocervical 
cancer,  in  contrast  with  the  epithelioma  of  the  vaginal  portion  of  the  cervix,  lies 
closer  to  the  broad  ligaments,  and  hence  the  earlier  invasion. 

The  histological  appearances 
have  been  described  in  Yol.  I, 
Chapter  XIY,  p.  493. 

The  surface  epithelium  mul- 
tiplies and  forms  new  glands, 
and  the  glands  themselves  pro- 
liferate and  penetrate  the  tissues 
in  all  directions.  The  growth 
is  an  exceeding  rapid  one,  and 
is  the  most  malignant  of  the 
uterine  carcinomata. 

Adeno-carcinoma  of  the  Body 
of  the  Uterus. — Adeno-carcino- 
ma of  the  body  of  the  uterus  in 
its  early  stages  is  usually  local- 
ized and  the  uterus  may  be  sub- 
normal in  size,  but  as  the  dis- 
ease advances  the  body  of  the 
uterus  enlarges  from  a  half  to 
three  times  its  normal  size. 
Macroscopically,  in  its  early 
stages  the  disease,  which  usu- 
ally begins  in  the  upper  part  of  the  uterine  cavity,  is  made  up  of  small  papillary 
and  dendritic  projections  from  the  general  level  of  the  mucosa,  while  at  the 
same  time  there  is  an  invasion  of  the  muscular  layers.  With  the  advance  of 
the  disease  the  entire  uterine  cavity  fills  with  masses  of  fleshy  papillary  excres- 
cences, and  the  muscularis  is  invaded  in  places  all  the  way  through  to  the  peri- 
toneum, so  that  the  uterus  is  converted  into  a  mere  shell  filled  with  the  disease 
which  shows  but  little  tendency  to  break  down. 


Fig.  454. — Adeno- carcinomatous  Nodule  Entirely  con- 
cealed WITHIN  THE  Cervix,  in  an  Early  Stage  of  the 
Disease. 


The  diagnosis  was  made  by  curettage 
Natural  size. 


Gyn.  Path.  No.  308. 


CANCER  OF  THE  UTERUS,  WITH  MYOMA  OR  TUBERCULOSIS. 


311 


Adeno-carcinoma  of  the  bodj  is  a  slow  growth,  sometimes  running  a  course 
of  five  years  from  the  initial  symptoms  ;  it  is  further  remarkable  for  the  slight 
tendency  it  shows  to  pass  beyond  the  limits  of  the  uterine  body,  to  invade 
either  the  cervix  below  or  the  parametrium. 

The  microscopical  appearances  are  those  described  in  Chapter  XIV. 


Fig.  455. — Adeno-carcinosia  of  the  Body  of  the  Uteris,  Limited  in  its  Downward  Growth  by  the 

Internal  Os. 

Note  the  cystic  condition  of  the  ends  of  the  tubes.    Small  myomata  in  the  wall  of  the  uterus.    Gyn.  Path. 
No.  345.     Natural  size. 


The  outgrowth  of  newly-formed  glands  is  greatly  in  excess  of  that  found  in 
cervical  carcinoma. 

The  general  rule  holds  good  that  the  histological  characteristics  of  the  tumor 
correspond  to  those  of  the  tissue  normally  found  in  the  part  from  which  the 
tumor  takes  its  origin. 

Von  Rosthorn,  Zeller,  and  others  have  shown  that  squamous  epithelium  is 
sometimes  present  in  the  body  of  the  uterus,  and  this  exjjlains  the  rare  occur- 
rence of  epithelioma  at  this  point. 

In  seventy-six  of  my  cases  Dr.  Cullen  found  that  fifty-two  were  epitheli- 
omata,  thirteen  adeno-carcinomata  of  the  cervix,  and  eleven  adeno-carcinomata 
of  the  body  of  the  uterus. 

Cancer  of  the  Uterus,  with  Myoma  or  Tuberculosis. — Cancer  of  the  uterus 
is  sometimes  found  associated  with  myoma  or  tuberculosis ;  in  tuberculosis  the 
association  appears  to  be  a  matter  of  pure  coincidence ;  it  is  possible  that  the 
reduced  state  of  health  brought  about  by  the  cancer  may  prepare  the  tissues 
for  an  easy  invasion  by  the  tubercular  disease.  In  myoma  the  tumor  may 
be  at  the  fundal  end  of  the  uterus  and  the  cancer  at  the  cervical  end,  or 
again  the  cancer  may  be  in  the  body  and  invade  the  mj^oraatous  tissue,  just  as 
it  ordinarily  invades  the  normal  museularis. 

The  chief  indication  for  operation  in  the  case  of  a  large  myomatous  uterus  in 
rare  instances  lies  in  the  hemorrhage  produced  by  an  undiscovered  cancer.  I 
have  seen  four  cases  of  this  kind  ;  in  one  of  them  (L.  W.,  lOCJO,  Nov.  23,  1891) 
63 


312 


ABDOMIXAL    HYSTERECTOMY    FOR    CARCINOMA    OF   THE    UTERUS. 


the  operation  of  salpingo-oopliorectoray  was  performed  for  a  myomatous  uterus 
to  check  severe  hemorrhages.  These  did  not  cease,  and  after  several  months  the 
patient  returned  for  a  radical  operation,  at  which  the  uterus  was  found  tilled 
with  the  fungating  masses  of  an  adeno-carcinoma. 

Pregnancy  Complicating  Carcinoma  of  the  Cervix. — 
From  time  to  time  isolated  cases  of  cancer  of  the  cervix  complicating  pregnancy 
have  been  reported,  but  for  our  chief  knowledge  on  the  subject  we  are  indebted 
to  Cohnstein,  Theilhaber,  and  Olshausen.  Scheibe,  in  an  inaugural  dissertation 
published  in  Halle  in  1893,  quotes  Winckel  as  having  observed  8  cases  in  15,000 

labors,  Sutugin  2  in 
9,000,  and  Stratz  12 
in  17,900;  in  oth- 
er words,  taking  all 
these  cases  together, 
a  percentage  of  0-04:7. 
From  Cohnstein's  sta- 
tistics we  learn  that 
where  carcinoma  of 
the  cervix  and  preg- 
nancy coexist  the  pa- 
tients are,  on  an  aver- 
age, much  younger 
than  those  where  car- 
cinoma alone  is  pres- 
ent. In  127  of  the 
cases  cited  by  Cohn- 
stein 86  were  appar- 
ently adeno-carcino- 
mata  and  41  epitheli- 
omata,  but  in  5  cases 
which  came  under 
Fehling's  personal  ob- 
servation 4  were  epi- 
theliomata  and  1  an  adeno-carcinoma.  The  clinical  history  is  practically  the 
same  as  noted  in  those  cases  where  no  pregnancy  exists,  plus  the  abdominal 
enlargement  and  the  swelling  of  the  breasts. 

Course  of  the  Pregnancy . — In  29  per  cent  of  Cohnstein's  cases 
the  patient  either  aborted  or  miscarried.  Of  those  advancing  to  term  the  same 
writer  found  that  36*2  per  cent  of  the  children  were  born  alive,  while  in  Theil- 
haber's  cases  47'2  per  cent  were  living  at  birth.  When  pregnancy  advances  to 
term,  labor  may  come  on  in  the  usual  way  and  progress  without  any  untoward 
symptoms,  but  in  some  cases  most  disastrous  results  may  follow.  If  the  growth 
is  far  advanced,  deep  tears  may  take  place  in  the  hard  but  friable  carcinomatous 
tissues,  and  the  bladder  or  rectum  may  be  laid  open.  In  some  instances  the 
uterus  ruptures  ;  Hermann  has  reported  rupture  in  11  out  of  180  cases. 


^ 


Fio.  4i\(\. — Adeno-carcincima  of  the  Body  of  the  Uterus. 

Showincr  large  globular  uterus  tilled  with  the  disease ;  nodules  of  the 
extension  of  the  carcinoma  through  to  the  peritoneal  surface  are  seen  be- 
tween the  left  tube  and  ovary.     July  25,  1894.     Natural  size. 


CANCER    OF    THE    UTERUS,    WITH    MYOMA    OR    TUBERCULOSIS. 


313 


Treatment. — Up  to  the  fifth  month  vaginal  or  abdominal  hysterectomy 
may  be  performed.     Most  operators  prefer  the  vaginal  route,  as  in  pregnancy, 


Fig.  457. — Adeno-carcinoma  of  the  Body  of  the  Uterus  cct  through  the  Anterior  Wall. 

In  spite  of  the  fact  that  the  whole  uterine  cavity  is  choked  with  the  disease,  it  does  not  invade  the  cervix. 
Same  as  Fig.  456.     July  25,  1894.     Ye  natural  size.' 


the  uterus  is  plastic,  and  it  is  possible  to  reach  with  ease  far  out  into  the  broad 
ligaments,  a  feat  much  more  difficult  in  tlie  case  of  the  non -pregnant  uterus. 


Fig.  458.— Adeno-carcinoma  of  the  Uterine  Body,  with    Metastatic  Nodules  in  the  Lymph   Chan- 
nels OF  THE  Left  Broad  Ligament  and  a  Nodule  in  the  Left  Round  Ligament. 

Almost  the  entire  bodv  is  converted  into  a  carcinomatous  mass,  while  the  cervical  portion  is  free.     \ 
large  gland,  about  2  centimeters  in  diameter,  removed  from  the  pelvic  wall  showed  nothing  but  hypertrui)iiy. 

In  the  later  months  Caesarean  section,  with  entire  removal  of  the  uterus,  has 
been  the  usual  procedure,  and  is  my  own  preference ;  but  recently  Fritsch  and 


314 


ABDOMINAL   HYSTERECTOMY    FOR   CARCINOMA    OF   THE    UTERUS. 


others  have  strongly  advocated  vaginal  hysterectomy.  In  these  cases  they  first 
sUt  the  cervix,  dehver  the  child  and  placenta,  and  claim  that  the  uterus  can  then 
be  removed/*^/'  vaginam  with  great  ease. 

In  inoperable  cases,  Csesarean  section  at  or  near  term  offers  the  best  chance 
for  the  child,  and  for  the  mother  it  is  better  to  continue  the  operation  by  ampu- 
tating the  uterus  at  the  cervix ;  in  other  words,  by  performing  the  Porro-Cffisa- 
rean  operation. 

Symptoms. — The  chief  symptoms  of  carcinoma  are  hemorrhage,  watery  or 
purulent  discharges,  and  pain. 

Hemorrhage  is  a  regular  concomitant  of  some  period  of  the  history  of  the 
disease,  but  is  not  often  noted  in  the  early  stages  ;  it  increases  in  frequency  and 

severity  as  time  goes  on. 

It  will  not  be  necessary  to  en- 
ter into  a  disquisition  upon  the 
differential  clinical  signs  in  all 
these  cases,  as  the  one  important 
difference  upon  which  the  diag- 
nosis of  cancer  depends  rests  upon 
the  revelation  of  the  cancerous  tis- 
sue under  the  microscope. 

One  of  my  cases  (J.  H.  A., 
San.,  260,  Dec.  13,  1895)  was  cu- 
retted for  uterine  hemorrhages  and 
an  adeno-carcinoma  found  ;  as  the 
bimanual  examination  showed  that 
the  body  of  the  uterus  was  not  en- 
larged while  the  cervix  was  great- 
ly thickened,  the  conclusion  was 
drawn  that  the  disease  was  local- 
ized in  the  cervix.  On  removing 
the  uterus,  however,  the  fundus 
was  found  to  be  the  seat  of  the 
neoplasm,  while  the  cervix  was 
extraordinarily  enlarged  by  a  cys- 
tic degeneration  extending,  from 
the  internal  to  the  external  os,  but 
not  visible  from  the  vaginal  side. 

The  age  at  which  this  disease 
usually  appears  renders  the  patient 
unsuspicious,  for  she  attributes  it  to  an  irregularity  of  the  menoj)ause,  or  to  a 
return  of  tlie  monthly  peiiods,  as  a  sort  of  a  rejuvenation. 

Pain,  too,  is  apt  to  be  a  late  symptom,  and  is  sometimes  entirely  wanting 
throughout  the  disease.  The  typical  distress  is  a  boring,  bearing-down,  tearing 
or  stabbing  pain,  which  is  referred  to  the  lumbar  and  sacral  region,  and  radiates 
down  the  legs  and  forward  into  the  lower  abdomen. 


Fig.  459. — Limited  Akea  of  Carcinoma  of  the  Fundus 

OF   THE    UtEKUS    ON    THE    l.EFT    SiDE. 

The  cervix  was  greatly  enlarged,  and  was  thought 
from  the  bimanual  examination  to  be  the  seat  of  the  dis- 
ease, on  account  of  the  tliickening  due  to  numerous  cysts 
in  its  substance,  none  of  which  were  visible  in  the  normal 
vaginal  portion.     San.  Nov.  21,  1895.     Natural  size. 


DIAGNOSIS.  315 

The  watery  discharge  and  1  e  u  c  o  r  r  h  e  a  are  regular  occurrences.  The  thin 
ichorous,  watery  discharge  is  one  of  the  most  characteristic  of  all  the  signs  of  the 
disease,  and  sometimes  forms  the  only  complaint.  Later  the  discharge  becomes 
purulent,  or  muco-purulent,  or  sanguino-purulent,  with  an  offensive  odor,  when, 
as  a  rule,  the  case  is  beyond  operative  interference. 

Cachexia  and  emaciation  are  not  always  present,  but  when  found,  especially 
in  disease  of  the  cervix,  they  are  almost  positive  signs  that  the  case  is  beyond 
relief. 

Diagnosis. — The  diagnosis  of  cancer  of  the  uterus  is  made  from  the  subjective 
symptoms,  from  touch,  inspection,  and  from  the  microscopic  examination  of 
curettings  or  small  pieces  of  tissue  excised  from  the  cervix. 

In  the  later  stages  of  disease  the  diagnosis  is  easily  made  from  the  symptoms, 
and  by  touch  and  inspection,  but  in  the  majority  of  such  cases  the  affection  is  too 
far  advanced  to  admit  of  a  radical  cure. 

In  the  earliest  stages  a  diagnosis  positive  enough  to  justify  a  radical  opera- 
tion can  not  be  made  without  a  microscopical  examination.  In  my  early  expe- 
riences, I  removed  the  uterus  in  four  cases  where  a  suspected  malignant  disease 
did  not  exist.  It  is  interesting  to  note  that  the  first  vaginal  hysterectomy 
for  cancer  in  1814  has  been  proved  by  recent  study  to  have  been  an  error  of 
this  kind. 

The  conditions  simulating  cancer  of  the  uterus  are  : 

1.  Hypertrophy  of  the  mucosa  with  ectropium  and  induration. 

2.  Ulceration  of  the  mucous  membrane  (erosion). 

3.  Cystic  cervical  glands. 

4.  Polypi,  which  should  always  be  excised  and  examined  microscopically  to 
exclude  malignant  changes. 

5.  Submucous  myomata. 

6.  Glandular  hypertrophy  of  the  mucous  membrane. 

7.  Endometritis  with  hemorrhage. 

In  the  later  stages  of  cancer  of  the  cervix  the  disease  forms  either  a  large 
fungoid,  friable  mass  at  the  vaginal  vault  with  fetid  discharges  and  frequent 
hemorrhages,  or  it  forms  a  craterous  opening  in  the  position  of  the  cervix  tilled 
with  friable  material,  bleeding  on  touch.  In  such  cases  there  can  be  no  doubt 
as  to  the  diagnosis. 

In  the  case  of  "  eroded,"  "  ulcerated,"  infiltrated  cervices  in  which  the  prac- 
titioner is  in  doubt,  he  must  either  secure  the  advice  of  a  competent  gynecolo- 
gist or  excise  a  wedge  of  the  suspected  area,  put  it  in  a  five-]>er- 
cent  solution  of  formalin,  and  send  it  to  a  reliable  pathologist  for  investi- 
gation. 

In  cancer  of  the  body  the  only  reliable  method  of  mak- 
ing the  diagnosis  is  by  the  microscopic  examination  of 
portions  of  the  endometrium  removed  by  curettage. 

Treatment. — The  treatment  of  carcinoma  of  the  uterus  is  either  radical  or 
palliative  ;  a  radical  plan  of  treatment  is  adopted  in  all  cases  in  which  the  dis- 
ease is  still  clearly  limited  to  the  uterus  and  its  innnediate  surroundings,  and  in 


316 


ABDOMINAL   HYSTEKECTOMY    FOE    CARCINOMA    OF   THE    UTERUS. 


which  there  is  a  reasonable  hope  that  it  may  be  completly  extirpated.    Palliative 
treatment  is  adopted  for  those  cases  which  are  beyond  radical  relief. 

One  of  the  most  important  objects  to  be  attained  in  the  immediate  future  is 
an  efficient  prophylaxis  in  avoiding  the  later  inoperable  stages  of  the  disease. 


Fig.  •iiKj. — Upekation  fur  CAiiriMiMA  of  tiik   Ltkkls. 
The  ureters  are  both  catheterized  in  order  to  make  them  stand  out  prominently  during  the  enucleation. 
On  the  right  sitle  the  peritoneum  lias  been  removed  and  the  bladder  divided  so  as  to  show  the  relations  ot 
the  ureter  to  the  uterine  and  pelvic  vessels.     A  part  of  the  pubic  rami  have  also  been  removed,  to  expose  the 
structures  better  to  view. 

We  are  not  yet  in  a  position  to  realize  anything  positive  by  any  process  of 
hygiene  or  of  medication  ;  there  is,  however,  one  suggestive  fact  in  the  his- 
tory of  carcinoma,  and  that  is  its  occurrence  with  such  frequency  in  parous 
women.  This  points  clearly  to  a  direct  relation  between  the  trauma  of  child- 
birth and  cancerous  affections  of  the  cervix,  and  suggests  the  need  of  some 


) 


Fig.  4tll. — Carcinoma  Uteri. 

Carcinoma  limited  to  the  posterior  cervical  and  the  y)Osterior  vaj^inal  walls.  It  has  apparently  been  en- 
tirely removed,  a  narrow  band  of  vaginal  mucosa  surrounding  the  margin  of  advancement  downward.  The 
parametrium  is  apparently  free  on  either  side.  The  right  and  left  pelvic  glands  with  lympli  cliannels  re- 
moved and  shown  above.  The  small  nodules  in  anterior  uterine  wall  are  myomata.  No  extension  of  car- 
cinoma to  the  body.     Dec.  23,  1895.     Anterior  view.     ^7  natural  size. 


TREATMEXT.  817 

such  rules  as  the  following  in  medical  practice  (see  New  York  Med.  Jour., 
Oct.  14,  1893) : 

Rules  for  the  Prevention  of  Cancer. — 1.  It  is  the  duty  of  the 
obstetrician  to  see  each  of  his  patients  at  his  office  from  two  to  three  months 
after  confinement,  and  to  examine  and  carefully  record  the  exact  condition  of 
the  various  pelvic  structures,  stating  accurately  just  what  lesions  have  been  pro- 
duced by  the  childbirth. 

2.  Cervical  lacerations  should  be  described  with  especial  care,  noting  the 
position  and  depth  of  tears  and  the  appearance  of  the  lijjs.  These  lacerations 
require  no  treatment  when  the  lips  are  thin,  uninfiltrated,  and  lying  together. 
Thick,  infiltrated,  and  everted  lips,  associated  mth  endocervical  catarrh,  call  for 
depletory  treatment  followed  by  repair  of  the  laceration  or  amputation. 

3.  Every  child-bearing  woman  who  has  passed  thirty  years  of  age,  and 
whose  condition  has  not  been  carefully  noted  in  this  way,  should  consult  a 
competent  physician.  If  the  cervical  lips  do  not  appear  sound,  she  should  be 
kept  under  observation  and  be  treated,  if  necessary,  or  examined  at  intervals 
of  six  or  eight  months. 

4.  Every  woman  of  thirty-three  or  over  who  has  a  cervical  tear  should  be 
examined  at  least  once  a  year  for  ten  years  or  longer  if  the  lacerated  cervix  does 
not  present  a  perfectly  healthy  appearance. 

5.  The  community  at  large  should  be  so  trained  by  the  pi-ofession  that  any 
woman  who  suffers  from  an  unusual  or  an  atypical  uterine  hemorrhage,  or  from 
any  unusual  discharge,  should  at  once  seek  competent  advice  as  to  its  cause,  and 
the  physician  should  not  rest  until  he  has  definitely  ascertained  its  source.  This 
rule  holds  with  increased  force  in  the  case  of  women  in  the  forties,  when  both 
patients  and  doctors  are  so  often  deluded  into  a  blind  waiting  for  IS'ature  to  relieve 
that  which  in  time  proves  to  be  beyond  the  resources  of  both  Xature  and  art. 

6.  These  rules  apply  with  special  force  to  patients  whose  family  history 
shows  a  liability  to  cancerous  disease. 

If  these  rules  were  conscientiously  observed  there  can 
be  no  doubt  but  that  thousands  of  lives  would  be  saved 
yearly  in  this  country  alone,  for  cancer  of  the  uterus  is 
a  disease  markedly  local,  and  accessible  and  eradicable 
in  its  earliest  stages. 

I  feel  that  while  we  ai-e  searching  for  the  cause  and  cure  for  cancer  in  all  its 
grades,  the  line  of  progress  in  the  immediate  future  for  the  gynecologist  clearly 
lies  in  the  direction  of  prophylaxis  and  anticipation,  either  preventing  the 
malady  or  discovering  it  in  time  to  eradicate  it. 

The  radical  plan  of  treatment  consists  in  the  removal  of  the  entire  uterine 
body,  whether  the  carcinoma  is  located  at  the  fundal  or  at  the  cervical  end. 
The  determination  that  a  case  is  suitable  for  radical  treatment  is  made  after  a 
careful  examination  of  the  pelvic  organs  conducted  in  the  following  manner  :  A 
digital  examination  of  the  vagina  is  made,  and  if  the  vaginal  cervix  is  found 
apparently  normal  to  the  touch  and  the  supravaginal  cervix  does  not  seem  to  be 
infiltrated  and  enlarged,  the  carcinoma  is  then  confined  to  the  fundus,  the  most 


318  ABDOMINAL    HYSTERECTOMY    FOR    CARCINOMA    OF   THE    UTERUS. 

favorable  site  for  permanent  relief  after  enucleation.  The  fundus  is  then  care- 
fully examined  binianually,  and  if  it  is  found  without  any  adhesions  and  freely 
movable  the  outlook  is  a  good  one,  in  spite  of  the  fact  that  the  body  of  the 
uterus  may  be  several  times  its  normal  size,  and  even  present  nodules  of  the  dis- 
ease which  can  be  felt  on  its  surface. 

If  the  body  is  adherent  and,  in  particular,  if  there  are  strong  intestinal  adhe- 
sions, and  this  is  associated  with  cachexia  and  marked  emaciation,  the  liability  of 
an  extension  of  the  disease  beyond  the  uterus  is  much  increased.  Even  under 
these  circumstances,  however,  if  the  patient's  general  condition  will  permit  it, 
she  should  have  the  benefit  of  an  exploratory  incision  to  determine  the  character 
of  the  adhesions  and  whether  the  disease  has  extended  beyond  the  possibility  of 
extirpation. 

When  the  cervix  is  affected  the  determination  is  somewhat  more  diificult,  as 
the  disease  may  extend  in  such  a  way  that  its  outermost  limits  can  not  be  accu- 
rately determined  by  the  most  careful  examination. 

In  investigating  a  case  of  cervical  carcinoma  the  various  modes  of  extension 
of  the  disease  must  be  borne  in  mind  and  each  avenue  examined  in  turn ; 
these  are  : 

1.  Extension  out  into  the  right  or  the  left  broad  ligaments  or  into  both  at 
once. 

2.  Extension  downward  into  the  vagina. 

3.  Extension  forward  into  the  bladder. 

4.  Extension  backward  into  the  utero  sacral  folds  and  so  into  the  rectum. 

5.  Extension  up  into  the  body  of  the  uterus  in  rare  instances. 

6.  Metastases  into  the  pelvic  glands,  rare. 

7.  Metastases  or  implantation  into  the  vagina  below  the  focus  of  the  disease, 
rare. 

In  the  early  stages,  when  the  cervix  is  not  much  enlarged  and  the  uterus  is 
probably  movable,  and  a  rectal  examination  shows  that  the  broad  ligaments  are 
probably  clear,  the  operation  may  be  undertaken  without  any  further  investi- 
gation. 

Later,  when  the  cervix  is  more  extensively  diseased,  the  minutest  possible 
examination  should  be  made  before  proceeding  to  operation  ;  if  the  uterus  is 
fixed  in  the  pelvis  and  the  broad  ligaments,  one  or  both,  are  found  hard,  thick, 
and  unyielding,  pinning  the  uterus  to  the  pelvic  wall,  the  case  may  be  rejected 
without  further  treatment.  Whenever  this  fixation  is  not  found,  then  a  minute 
categorical  investigation  should  l^e  made,  and  it  is  always  my  own  preference  to 
do  this  by  putting  the  patient  under  the  inllueiice  of  an  anesthetic. 

I  then  inspect  the  vagina  for  any  evidences  of  an  implantation  of  the  disease 
low  down,  or  for  evidence  of  the  extension  of  the  disease  over  the  vaginal  wall 
in  such  a  superficial  form  that  it  might  escape  the  tactile  sense  if  not  first  recog- 
nized by  the  increased  injection  shading  off  into  the  normal  vagina  below.  In 
looking  into  the  bladder,  the  evidences  of  an  early  extension  in  this  direction 
are  often  evident  in  the  form  of  a  hyperemic  area  of  the  base  with  tits  of  ede- 
matous tissue. 


Fici.  462. — DoLiiLE  IIydkolketek  iJLK  TO  Advanced  Canlei:  ue  the  Cekvix    Lteki. 

The  atrophic  and  inflammatory  chanjjes  due  to  tlie  cancer  are  phunly  visible  in  the  adhesions  ot"  tlic 
hiadtler  to  the  uterus,  and  in  the  cicatricial  tissue  and  adhesione  between  tlie  ureters  and  about  tiie  kidneys. 
Autopsy,  March  2,  1896.     %  natural  size. 


Pig.  463. — Autopsy  on  a  casu  of  e:u (i\ix  \.  iili    cnnpression  of  the  ureters,  produciiii^ 

hydroureter;  double  ureter  on  the  left  and  suigie  on  the  riffht  (faintly  seen).  The  peritoneum  i.s  opened  and 
the  uterus  and  bladder  pulled  to  the  right,  to  show  the  double  ureter  compressed  and  kinked  at  the  pelvic 
floor.     Autop.sy,  June  22,  1896. 


TREATMENT.  319 

By  touch,  however,  the  most  important  information  is  secured  ;  when  the 
disease  is  advanced  in  the  vaginal  direction  the  vagina  feels  shortened  and  the 
fornices  are  obliterated.  If  the  anterior  lip  alone  is  involved,  the  extension  may- 
be evident  down  the  anterior  vaginal  wall,  and  the  hard  cervical  mass  often 
seems  fastened  to  the  bladder. 

An  extension  posteriorly  toward  the  rectum  is  recognized  by  the  want  of 
mobility  of  the  posterior  cervical  lip,  which  seems  fastened  to  the  sacrum  to 
which  it  is  sometimes  drawn  up,  and  examination  through  the  rectum  will  show 
the  extent  of  the  disease  in  this  direction. 

An  extension  of  the  disease  ujDward  into  the  uterine  cavity  is  rare,  and  usually 
only  occurs  in  cases  so  far  advanced  in  other  directions  that  enucleation  is  impos- 
sible ;  further  than  this  it  has  no  significance,  as  the  entire  uterus  is  removed 
at  the  operation. 

Extension  out  into  the  broad  ligaments  can  only  be  suitably  investigated 
through  the  rectum  by  carrying  the  index  finger  well  above  the  ampulla  and 
back  of  the  uterus.  The  base  of  each  broad  ligament  must  be  carefully  studied 
from  its  cervical  to  its  pelvic  attachment ;  a  thick,  round,  hard  mass  attached  to 
the  cervix  and  extending  out  to  the  pelvic  wall  in  all  cases  represents  the  exten- 
sion of  the  disease  ;  a  slight  thickening,  and  a  condition  feeling  like  strings  in 
the  broad  ligament,  scarcely  impairing  its  mobility  while  probably  indicating 
also  extension  of  the  disease,  is  in  some  cases  due  to  inflammatory  deposits  which 
clear  up  after  the  removal  of  the  uterus.  In  these  eases  the  patient  should  be 
given  the  benefit  of  doubt.  Enlarged  glands  may  sometimes  he  felt  just  posterior 
to  the  broad  ligaments  or  at  the  pelvic  brim,  especially  in  the  bifurcation  of  the 
common  iliac  artery.  A  glandular  metastasis  is  one  of  the  late  sequelae  in  car- 
cinoma of  the  uterus,  and  such  a  discovery  in  no  way  contra-indicates  a  radical 
plan  of  treatment.  I  have  repeatedly  taken  out  enlarged  glands  in  the  course 
of  an  operation,  and  in  hut  one  instance  was  any  evidence  of  carcinoma  found 
in  them. 

In  one  case  of  advanced  carcinoma  of  the  body  I  dissected  out  a  hard  gland 
in  the  right  side  on  the  pelvic  brim,  al)Out  2  centimeters  in  diameter,  which  was 
unhesitatingly  pronounced  carcinomatous  from  its  macroscopic  appearances,  but 
the  microscope  showed  that  it  was  simply  a  hypertrophy. 

In  concluding  whether  or  not  to  operate,  the  patient  should  in  all  cases  have 
the  benefit  of  any  reasonable  doubt,  and  the  operator  must  not  be  too  exacting 
in  restricting  his  indications.  I  have  operated  several  times  where  the  disease 
was  found  so  advanced  that  there  could  be  no  reasonable  question  but  that 
some  portion  of  it  was  left  behind,  and  this  was  confirmed  by  a  microscopic 
examination  of  the  specimen,  which  showed  cancer  cells  i-ight  up  to  the  cut  edge 
of  the  broad  ligament,  and  yet  one  of  these  patients  enjoyed  i)erfect  health  for 
five  years,  when  the  disease  reappeared  in  the  glands  of  the  neck  ;  another  had  a 
local  return  after  thi-ee  years  of  good  health,  and  two  others  are  living,  appar- 
ently in  perfect  health,  three  and  four  years  after  the  operation. 

I  am  even  willing  to  extend  the  limit  of  the  scope  of  the  radical  operation  to 
cases  which  manifestly  can  not  be  permanently  cured,  but  in  which  the  uterus 


320 


ABDOMIXAL    HYSTERECTOMY    FOR    CARCINOMA    OF    THE    UTERUS. 


can  be  removed  without  great  difficulty.  This  may  be  demanded  by  the  insist- 
ence of  a  patient  who  is  utterly  demoralized  by  the  knowledge  that  she  has  a 
cancer  and  insists  upon  active  measures  for  her  relief,  as  well  as  for  the  purpose 
of  relieving  septic  symptoms,  pyometra,  and  the  risks  of  hemorrhage. 

The  disease  will  often  then 
return  in  the  pelvis  without  pain, 
without  hemorrhage,  and  with- 
out any  extensive  breaking  down 
of  the  tissues  ;  and  a  tranquil  end 
may  be  secured  either  through 
death  from  exhaustion  or  by 
uremia. 

Radical  Operation . — 
The  radical  operation  contem- 
plates the  removal  of  the  entire 
uterus  in  the  hope  of  eradicat- 
ing the  disease ;  it  is  done  either 
by  the  vaginal  or  the  abdominal 
routes. 

The  abdominal  route  allows 
a  wide  dissection  of  the  broad 
ligaments,  with  the  removal  of 
all  the  pelvic  connective  tissue 
out  to  the  bony  walls,  as  well  as 
the  removal  of  any  enlarged 
glands  found  in  the  pelvis  or 
al)out  its  brim ;  it  is  therefore 
to  be  preferred  in  all  cases  to 
the  vaginal  route  where  the  ex- 
tirpation is  limited  to  the  utenis, 
and  the  tissues  in  its  immediate 
vicinity. 

Two  objections  to  the  abdom- 
inal extirpation  are,  that  it  con- 
sumes more  time,  lasting  from 
an  hour  to  an  hour  and  a  half, 
or  even  two  hours,  and  that  it 
is  far  more  difficult  to  do  than 
the  vaginal  operation ;  the  first  objection,  however,  is  outweighed  by  the  great 
advantage  of  a  wider  extirpation,  and  the  second  will  be  overcome  by  practice, 
developing  the  requisite  technical  skill. 

Preparatory  Treatment . — In  addition  to  rest  in  bed  and  such  build- 
ing-up measures  as  are  adopted  in  all  cases  wliere  there  is  a  depressed  physical 
condition,  it  is  especially  important  to  secure  thorough  evacuation  of  the  bowels 
before  proceeding  to  operation. 


■ 

1 

P 

> 

/  * 

•J^      / 

-  -.  ] 

1 

t 

r    / 

P5* 

.  / 

'V  k  v^MiiwalH 

■ 

m 

\ 

m 

■ 

,• 

1 

^ 

I^HHb.' 

( 

Fig.  404. — The  Upper  Half  ok  a  IIvuuoureter,  and  Hy- 
dronephrosis  FROM  CoMPRESSIOX  OF  THE   RiOHT  UrETER 

BY  A  Cancerous  Cervix. 

The  kidney  (A')  is  embedded  in  adhesions.  The  kinked 
ureter  is  conipres.sed  or  .strictured  by  the  ovarian  vessels 
which  cross  it  at  the  level  of  the  lower  border  of  the  kid- 
ney.    Autopsy,  March  2, 1896.     Natural  size. 


PLATE  XV 


M  Brodel.fec, 


Lilh ,  LPran^  &Co,  Bostnn  .U  3  A 


DESCRIPTION  OF  PLATE  XVTtI  , 

Radical  operation  fov  cancf'r  of  fK^ntenm  the  glands 

removed  in  a  sf  d furcation  and 

behind  the  iuterru .    _.     ,. 

On  th«  left  side  the  method  of  splitting  the  peritoneum  to  expose  the  glands  is 


1      --1    :1 


of 
th^' 
to  - 


PLATE  XVI 


M.Brrio&.Ter 


LiihLPranliCj 


r^nAiiur*  i'ujiijjiAij    li  icsxis,itiiv^i«jju.  i    run 


the  disease  occupies  the  cervix,  a  thorough  cure' 


Where   there  are  good   reasons 'for  not  giving  ti 
aettage  as  a  preliminary  step  imme' ' 

-  lu'         ■ 

prelimii  ttiisre  a  week  c  fore  operation  li 

tiou  is  freed  of  the  • 

iisHUe   iv 

"'   *'"    '        '^'         ''  :vi      iijii-'ii/n       1-     a  1 /.i;  ii_n '11' 

this  time. 
Operation  for  Abdominal  Hysterectomy  for  Cancer. — It 

W.  A.  Freimd  {Vol/.:    ^  '•'■      ''    -  .    X.    i"->    - 

'.f  removinj^  tlie  chjkPESCRIPTION  OF  PLATE  XVIII. 

Radical  operation 'for  cancer  of  tiie"  uterus,  snowing  the  locations  of  the  glands 
removed  in  a  series  of  cases  above  'tHfe'cominoli' iKac  artery,  in  the  bifurcation  and 
behind  the  internal  iliac  artery.        '  • '   <•)'*■;  ,      ,  ■  I    > 

'  On  the  left  side  the  method  of  splitting  the  peritoneum  to  expose  the  glands  is 
demonstrated,  while  on  the  right  it  is  opened,  laying  bare  the  iliac  glands. 

Catheters  inserted  in  the  ureters  cause  them  to  stand  out  prominently.  The  stumps 
of  the  ligated  ovarian  vessels  and  the  round  ligaments  are  seen  on  the  outer  edge  of 
the  peritoneum  ;"  the  ligated  uterine  vessels  appear  deep  down  on  the  pelvic  floor  close 
to  and  on  the  outside  Of  the  ureters. 


fir/z  :i':j 


^\^ 


sbrr^Jv 


^K 


bnirfsd 


fmoif{  h 


OPERATION    FOR    ABDOMINAL   HYSTERECTOMY    FOR    CANCER.  321 

If  the  disease  occupies  tlie  cei'vix,  a  thorongli  curettage  should  be  done,  as 
described  in  ChajDter  XIY,  as  a  rule,  a  week  or  ten  days  before  extirpating 
the  uterus,  at  the  time  the  examination  is  made  to  determine  the  extent  of  the 
disease.  Where  there  are  good  reasons  for  not  giving  the  anesthetic  twice, 
the  curettage  may  be  done  as  a  preliminary  step  immediately  before  the  extir- 
pation. 

A  preliminary  curettage  a  week  or  two  before  operation  has  the  following 
advantages :  The  field  of  operation  is  freed  of  the  necrotic  tissue,  reducing  the 
risks  of  infection  and  lessening  the  danger  of  implantation  of  the  cancer  cells 
into  the  healthy  tissue  during  the  operation. 

Tissue  for  microscojDic  examination  is  secured,  and  sometimes  an  operation 
which  had  previously  seemed  feasible  is  abandoned  on  account  of  the  extent 
of  the  disease  discovered  at  this  time. 

Operation  for  Abdominal  Hysterectomy  for  Cancer. — It  is  not  many  years  since 
W.  A.  Freund  {Volk.  Samni.  Uin.  Yoi'tr.,  Ko.  133,  1878)  described  a  method 
of  removing  the  cancerous  uterus  through  the  abdomen  ;  the  mortality  following 
this  procedure  was,  however,  so  great  that  few  imitators  were  found.  In  a  case 
upon  which  I  operated  in  1889  I  was  discouraged  from  further  attempts  by  the 
excessive  hemorrhage  during  the  operation,  and  the  ligation  of  a  ureter  with  a 
fatal  result. 

A  most  important  step  was  taken  by  K.  Pawlik  {Interned.  Min.  Rundschau, 
"Wien,  1889),  who  introduced  bougies  into  the  ureters  so  as  to  mark  them  out 
during  the  removal  of  the  uterus  and  adjacent  pelvic  cellular  tissue. 

My  own  method  of  exposing  the  ureteral  orifices  by  an  atmospheric  distention 
of  the  bladder,  and  so  introducing  the  bougies  under  direct  insjjection,  has  made 
Pawlik's  plan  easily  available. 

Another  advance  in  the  technique  of  hysterectomy  for  carcinoma  of  the 
uterus  was  made  by  A.  Mackenrodt  {Beitr.  z.  Yerhess.  d.  Dauerresultate  d.  Total- 
extirjKition  hei  Carcinoma  Uteri.  Zeits.f.  Geburt.  it.  Gi/ndk.,  1894,  p.  157)  in 
the  removal  of  both  broad  ligaments  with  the  uteres. 

The  last  important  step  has  been  taken  simultaneously  and  independently  by 
three  operators,  J.  G.  Clark  (.Johns  Hopkins  Hospital  Bulletin,  July-Aug., 
1895,  and  Feb.-March,  1896 ;  E.  Ries,  Zeitschr.f.  Geburts.  u.  Gynak.,  Bd.  xxxii, 
1895,  p.  26f),  and  Rumpf,  Zeitschr.  f.  Gehurts.  v.  Gyniik.,  Bd.  xxxiii,  1895,  p. 
212).  Each  of  these  operators.  Mashing  to  establish  a  parallel  between  the  wide 
extirpative  operations  upon  cancerous  breasts  associated  with  the  removal  of  the 
axillary  glands  and  the  cancer  of  the  uterus,  proposed  as  far  as  possible  to  re- 
move the  pelvic  glands,  and  in  this  way  to  make  the  operation  more  thorough 
and  to  reduce  the  percentage  of  relapses. 

Kies  dwelt  especially  upon  the  im])ortance  of  removing  the  uterus,  broad  liga- 
ments, and  the  iliac  glands  found  in  the  bifurcation  of  the  common  iliac  artery 
and  in  varying  number  on  both  sides  of  and  along  the  iliac  vessels.  Rumpf,  who 
was  the  first  to  operate  upon  the  human  being,  conducted  an  extensive  dissec- 
tion, removing  the  l)roa<l  ligaments,  the  parametric  tissues,  dissecting  out  the 
ureters  and  much  of  the  pelvic  connective  tissue  below  them  ;    in  atldition, 


322  ABDOMINAL   HYSTERECTOMY    FOR    CARCINOMA    OF   THE    UTERUS. 

Douglas's  folds  with  their  neighboring  tissues  and  the  floor  of  Douglas's  pouch 
were  also  removed  with  the  upper  part  of  the  vagina. 

The  facility  and  success  of  the  Ries-Rumpf-Clark  operation  as  developed  in 
my  clinic  has  been  greatly  enhanced  by  the  passage  of  catheters  into  the  ureters 
previous  to  the  operation  as  before  mentioned,  converting  them  for  the  time 
into  rigid  cords,  splinted  out  against  the  pelvic  wall  and  yet  within  easy  touch, 
and  relieving  the  operator  of  the  embarrassment  arising  from  any  doubt  as  to 
their  location  during  the  application  of  the  ligatures.  These  are  tlie  steps  in 
the  operation  : 

(a)  Catheterization  of  the  ureters. 

(b)  Closing  the  cervix  in  carcinoma  of  the  body,  or  of  the  vaginal  vault  in 
carcinoma  of  the  cervix. 

(c)  Thorough  disinfection  of  the  vagina,  which  is  then  filled  with  a  loose  iodo- 
form gauze  tampon. 

(d)  Elevation  of  the  pelvis  and  abdominal  incision,  exposing  the  field  of 
operation. 

(e)  Ligation  of  the  upper  parts  of  both  broad  ligaments,  including  the  round 
ligaments. 

(f)  Detachment  of  the  vesical  peritoneum  and  of  the  bladder  down  to  the 
vao-inal  vault. 

(g)  Ligation  of  the  right  and  left  uterine  arteries  at  their  origin  at  the  inter- 
nal iliac  arteries. 

(h)  The  dissection  and  freeing  of  the  uterine  arteries  with  all  the  adjacent 
cellular  tissue  from  the  pelvic  wall  in  toward  the  vault  of  the  vagina. 

(i)  Setting  free  the  ureters  which  are  lifted  up  and  away  from  the  field  of 
operation. 

(j)  Ligation  of  the  large  uterine  veins  above  and  below  the  ureter  out  near 
the  pelvic  wall. 

(k)  Enlarged  glands  found  on  the  pelvic  floor  must  be  taken  up  with  the 
cellular  tissue. 

(I)  The  uterus,  with  broad  wings  of  connective  tissue,  is  freed  down  to  its 
vaginal  attachment,  and  the  vagina  opened  at  least  2  centimeters  below  the  low- 
est limit  of  the  disease,  anterior  to  the  cervix,  with  a  thermo-cautery. 

(m)  The  opening  in  the  vaginal  vault  is  continued  around  to  the  right  and 
to  the  left,  clamping  any  actively  bleeding  vessels  until  the  uterus  is  entirely 
freed. 

(n)  As  soon  as  the  vagina  is  incised  anteriorly  a  loose  iodoform  gauze  pack  is 
pushed  in,  and  as  soon  as  the  opening  is  large  enough  to  permit  it,  the  lower  part 
of  the  uterus  and  the  vaginal  vault  are  enveloped  in  gauze,  so  as  to  prevent  any 
discharge  from  contaminating  the  wound  area  ;  the  gauze  wrap  aifords  an  excel- 
lent hold  for  the  operator  in  making  traction  upon  the  uterus  as  it  is  gradually 
delivered. 

(o)  Bleeding  vaginal  vessels  are  controlled  by  catgut  ligatures  passed  through 
the  vaginal  walls  but  not  including  the  mucosa. 

(p)  The  entire  wound  surface  is  minutely  inspected,  all  oozing  vessels  con- 


OPERATION    50R    ABDOMINAL    HYSTERECTOMY    FOR    CANCER. 


323 


trolled  by  catgut  ligatures,  and  reinforcing  ligatures  applied  to  any  important 
vessels  where  the  first  ligation  seems  insecure. 

(cj)  The  vesical  peritoneum  and  the  peritoneum  of  the  anterior  layers  of  the 
broad  ligaments  is  drawn  back  and  united  by  continuous  suture  to  the  perito- 
neum of  the  posterior  layers  of  the  broad  ligaments  and  Douglas's  cul-de-sac. 

(r)  If  there  has  been  no  contamination  the  abdomen  may  be  closed  at  once. 
If,  however,  there  has  been  some  escape  of  the  uterine  contents  over  the  wound 
and  into  the  peritoneum,  the  pelvic  cavity  should  be  thoroughly  washed  out  after 
letting  the  patient  down  to  a  horizontal  position  before  closing  the  abdomen. 

(s)  The  vaginal  gauze  is  changed,  and  a  piece  of  washed-out  iodoform  gauze 
passed  loosely  up  between  the  lips  of  the  wound  to  give  a  httle  support  to  the 
sutured  peritoneum  above, 
and  to  avoid  any  accumu- 
lation of  fluids  within  the 
wound  area. 

The  catheterization  of  the 
ureters  constitutes  one  of  the 
most  important  steps,  as  by 
means  of  the  catheters  or 
bougies  two  valuable  objects 
are  attained,  as  already  men- 
tioned :  First,  the  elasticity 
of  the  catheter  tends  to  push 
the  ureter  out  close  to  the 
pelvic  wall,  out  of  the  way 
of  the  operation,  and  second, 
by  means  of  the  catheter,  the 
ureter  is  converted  into  a 
hard  cord  which  can  be  felt 
at  all  times  during  the  enu- 
cleation, so  insuring  its  safe- 
ty from  injury. 

The  best  plan  is  to  intro- 
duce the  catheters  before  giv- 
ing the  patient  the  anesthetic, 
80  as  to  shorten  the  time  of 
the  anesthesia  and  to  avoid  the 

additional  shock  incident  to  placing  her  in  the  knee-breast  position  and  catheter- 
izino;  while  under  the  anesthetic.  I  have  several  times  catheterized  the  ureters 
before  doing  a  hysterectomy,  without  elevating  the  pelvis  at  all,  by  simply 
directing  the  speculum  down  to  that  part  of  the  bladder  where  the  ureteral  ori- 
fices would  naturally  be  looked  for,  and  sliding  it  over  the  mucous  surface  until 
first  one  orifice  is  seen  and  cathetei-ized  ;  then  the  speculum  was  withdrawn  and 
re-inserted  beside  the  catheter,  and  the  opposite  orifice  was  sought  out  aud 
catheterized. 


Fig.  465. — The  Kelatiuns  of  the  Ureter  and  Bladder  to  the 
Uterus  akd  Vagina. 

The  right  ureter  is  seen  crossing  under  the  uterine  artery  at  a 
little  distance  from  the  cervix  and  entering  the  collapsed  bladder 
in  front.  The  uterus  is  above  and  to  the  left.  The  lower  part  of 
the  figure  is  made  up  of  vagina  on  the  left  and  urethra  on  the 
right,  with  a  slight  sulcus  between. 


324 


ABDOMINAL   HYSTERECTOMY    FOR   CARCINOMA    OF   THE    UTERUS. 


When  the  Inroad  ligaments  are  much  involved  it  will  sometimes  be  found  im- 
possible to  pass  the  end  of  the  catheter  more  than  3  or  4  centimeters  into  the 
ureter.  This  would  seem  to  be  due  to  the  fact  that  one  of  the  prime  conditions 
necessary  to  the  passage  of  the  catheter  is  a  certain  amount  of  mobility  on  the 
part  of  the  ureter,  and  when  this  is  impaired  l)y  fixation  in  an  inflammatory  mass 
the  end  of  the  catheter  butts  up  against  the  mass  and  is  unable  to  turn  the  sharp 

angle  formed  and  so  to  find  the 
lumen.  This  condition  is  diagram- 
matically  represented  in  Fig.  466. 

The  closure  of  the  cervix  by 
means  of  stout  silk  ligatures  passed 
through  both  lips  in  the  form  of 
mattress  sutures  is  the  first  step  in 
operation  and  should  never  be  omit- 
ted, as  it  forms  the  best  means  of 
preventing  the  escape  of  cancerous 
material  from  the  uterus  over  the 
wound  surface  during  the  enuclea- 
tion. After  tightly  tying  the  liga- 
tures they  are  cut  short,  the  abdo- 
men is  cleansed,  the  pelvis  elevated, 
and  a  free  abdominal  incision  made, 
varying  in  its  length  according  to 
the  thickness  of  the  abdominal  wall 
and  the  depth  of  the  pelvis.  As  a 
rule,  the  incision  should  extend  one 
third  or  one  half  way  up  to  the  um- 
bilicus, in  order  to  give  a  perfect  ex- 
posure of  the  pelvic  viscera  and  to 
allow  the  operator  to  use  his  hands 
with  entire  freedom  in  all  the  man- 
ipulations necessary  throughout  the 
operation. 

Tlie  enucleation  is  begun  by 
grasping  the  uterus  and  one  tube 
and  ovary  and  dravdng  them  up- 
ward and  out  of  the  abdomen  when 
possible,  and  li  gating  the  ovarian 
vessels  near  the  brim  of  the  pelvis  ; 
the  round  ligament  is  next  ligated 
and  clamps  applied  to  the  ovarian  vessels  and  round  ligaments  on  the  uterine 
side,  after  which  the  top  of  the  broad  ligament  is  opened  by  an  incision  made 
between  the  ligatures  and  clamps.  If  the  case  is  one  of  cancer  of  the  cervix  the 
ligatures  may  he  safely  applied  at  a  point  nearer  to  the  uterus :  in  advanced  can- 
cer of  the  body,  however,  it  is  better  to  apply  them  well  away  from  the  uterus, 


Fig.  466. — Diagram  showixg  why  the  Bougie  Some- 
times REFUSES  TO  PaSS  ON  Up  THE  UbETER  IN  CAR- 
CINOMA OF  THE  Cervix. 

The  ureter  ordinarily  yield.s  a  little  as  the  bougie 
passe.s  upward  toward  the  kidney ;  this  movement,  by 
which  it  accommodates  itself  to  the  eliisticity  of  the 
bougie,  is  prevented  when  the  ureter  is  embedcled  in  a 
carcinomatous  mass,  and,  as  a  consequence,  an  angle  is 
formed  just  at  tiie  entrance  of  the  fixed  portion,  beyond 
which  it  is  difficult  to  coax  tlie  instrument.  Sometimes 
the  ureter  is  markedly  kinked  in  the  neighborhood  of 
the  di.seased  area  fsee  Fig.  46-3).  It  is  still  important, 
however,  to  insert  the  boucrie  as  fiir  as  possible,  as  the 
position  of  the  point  serves  to  locate  the  ureter. 


OPERATION    FOR    ABDOMINAL    HYSTERECTOMY    FOR    CANCER. 


325 


on  account  of  the  possibility  of  cancerous  elements  being  contained  in  the  Ivin- 
phatics  of  the  up^jer  broad  ligament  or  in  the  round  ligaments.  Such  a  con- 
dition is  well  shown  in  Fig.  458. 

After  opening  the  broad  ligament  in  this  way  the  incision  should  then  l)e 
continued  on  around  in  front  of  the  uterus  to  the  opposite  round  ligament,  sepa- 
rating the  vesical  peritoneum  from  its  uterine  attachment. 

The  operator  then  in  a  similar  manner  ligates  and  opens  up  the  other  broad 
ligament,  and  pulls  up  the  uterus,  while  at  the  same  time  with  a  sponge  held  in 
the  grasp  of  a  pair  of  forceps  he  pushes  down  the  vesical  peritoneum  still  fur- 
ther, detaches  the  bladder,  dissecting  it  loose  with  a  scalpel  when  it  adheres 
tightly,  until  it  is  quite  free  from  the  uterus  and  vaginal  vault.  Any  bleeding 
vesical  vessels  may  be  clamped  temporarily  or  tied  with  catgut. 


Fio.  4<i7. — OiTLixE  Diagram  of  the  Steps  of  the  Radical  Opeuatiox  fok  Cancek  of  the  Cekvix. 

The  incisions  are  made  in  the  directions  indicated  by  the  arrows,  following  the  black  lines.  The  loops 
indicate  the  positions  of  three  important  lijratures  on  either  side.  Tiie  vacrina  (  I'a)  may  be  opened  from 
either  .side,  from  within  out,  as  indicated,  or  from  without  in.  I'r  is  the  ureter,  Ijehind  which  the  uterine 
artery  is  tied. 

The  succeeding  steps  in  the  operation  are  the  most  difficult  and  the  most 
critical,  for  the  operator  has  now  to  ligate  the  uterine  ai-teries  at  a  point  distant 
from  the  uterus,  to  free  the  ureter  from  its  relations  to  the  pelvic  connective  tis- 
sue, to  ligate  the  large  uterine  veins,  and  to  dissect  out,  with  the  lower  segment 
of  the  uterus,  the  entire  mass  of  pelvic  connective  tissue  between  the  cervix  and 
the  pelvic  walls,  sometimes  including  a  chain  of  large  glands. 

The  best  place  to  ligate  the  utenne  artery  is  well  back  in  the  pelvis  at  its 
origin  from  the  anterior  branch  of  the  internal  iliac ;  at  this  point,  although  not 
far  from  the  ureter,  it  lies  more  parallel  to  it  and  is  not  so  difficult  to  isolate  as 
it  is  in  the  neighborhood  of  the  cervix,  where  it  is  surrounded  by  large  veins, 


326 


ABDOillNAL   HYSTERECTOMY    FOR    CARCINOMA    OF   THE    UTERUS. 


and  where  the  ureter  crosses  beneath  it  at  a  right  angle.  The  artery  is  exposed 
bj  retracting  the  anterior  and  posterior  layers  of  the  broad  ligament  and  sepa- 
rating the  cellular  tissue  by  a  blunt  dissection,  which  is  very  conveniently  done 
by  a  three-pronged  instrument  like  a  small  pitchfork,  all  the  way  down  to  the 


Fig.  468. — Hysterectomy  fou  (Jaucixoma  of  the  Cervix. 


The  abdomen  is  incised  and  the  left  broad  liorament  opened  up.  The  stump  of  the  left  ovarian  ves.sela 
is  seen  at  the  pelvic  brim,  and  that  of  the  round  ligament  in  front,  by  the  bladder.  The  uterus  is  grasped 
by  museau  forceps  and  drawn  forcibly  to  the  right,  while  a  blunt  dissection  is  carried  on  down  to  the  base 
of  the  left  broad  ligament,  exposing  the  uterine  artery  and  tracing  it  back  to  its  origin  in  the  loose  pelvic 
cellular  tissue.  The  ureter,  splinted  by  a  bougie,  is  plainly  seenand  felt  on  the  pelvic  floor  just  beneath 
the  uterine  artery. 

pelvic  floor  posteriorly,  where  the  artery  may  be  distinctly  felt  pulsating.  The 
artery  may  now  be  easily  isolated,  lifted  up,  and  ligated  with  a  fine  silk  ligature 
passed  by  means  of  an  aneurism  needle  ;  the  artery  is  cut  about  half  a  centimeter 
beyond  the  ligature  and  the  dissection  continued  in  toward  the  cervix. 

The  operator  is  able  to  assure  himself  of  the  position  of  the  ureter  before 
ligating  the  uterine  artery,  either  by  means  of  the  bougie,  or  when  it  has  not 
been  possible  to  introduce  the  bougie,  by  simply  gathering  up  the  uterine  artery 
and  the  tissues  parallel  to  it  between  the  thumb  and  forefinger  and  letting  them 
slip  between  the  fingers  ;  the  flat  cordlike  sensation  of  the  ureter  caught  in  this 
way  is  perfectly  characteristic,  and  it  is  not  necessary  to  see  it  to  know  where  it 
is  and  to  feel  assured  that  it  is  out  of  the  way  of  harm. 

The  uterine  artery,  tied  and  divided  as  described,  is  now  caught  by  a  pair  of 
artery  forceps  and  drawn  up,  and  the  dissection  of  the  cellular  tissue  continued 
down  toward  the  uterus,  at  first  keeping  close  to  the  pelvic  wall,  so  as  to  leave 


OPERATION    FOR   ABDOMINAL    HYSTERECTOMY    FOR    CANCER.  327 

no  tissue  between  it  and  the  cervix ;  during  this  enucleation  the  course  of  the 
ureter  is  kept  constantly  in  view,  and  wherever  the  dissection  encroaches  upon 
it,  it  is  freed  vnthout  mjury.  It  is  especially  important  not  to  bruise  the  coats 
of  the  ureter,  and  not  to  cut  the  little  tortuous  artery  on  its  external  surface,  in 
order  to  avoid  the  risk  of  the  sloughing  of  its  coats  subsequent  to  the  operation 
and  the  formation  of  a  uretero-vagiual  fistula. 

As  the  dissection  is  continued  on  down  toward  the  vaginal  vault  below  the 
cervix,  the  detached  tissue,  which  began  in  a  point  with  the  uterine  artery, 
widens  out  into  a  broad-based  cone,  attached  to  the  cervix  like  a  wing. 

Down  on  the  floor  of  the  pelvis  two  or  three  large  veins,  often  a  centimeter 
in  diameter,  are  exposed  and  tied ;  one  of  these  veins  is  usually  found  lying 
below  the  ureter  at  a  point  where  it  would  not  be  expected,  and  is  therefore 
more  liable  to  injury  before  ligation.  Care  should  be  taken  to  ligate  the  veins 
both  distally  and  proximally,  or  at  least  to  clamp  them  on  their  distal  side. 


Fio.  469. — Tlie  uterus  {F)  is  pulled  farther  to  the  riorht,  and  the  uterine  artery  tied,  eut  otf,  and  dissected 
away  from  the  ureter  (  r>)  with  a  mass  of  pelvic  cellular  tissue  and  glands  (not  shown).  1',  posterior  layer 
of  the  peritoneum  ;  ^,  bladder;  C,  cervix;  )',  vajrina. 

This  extensive  detachment  of  the  cellular  tissue  should  be  completed  on  both 
sides  before  proceeding  with  the  final  steps  of  the  enucleation. 

Enlarged  glands  should  always  be  looked  for  on  the  jielvic  floor  and  close  to 
63 


328  ABDOMINAL   HYSTERECTOMY    FOR    CARCINOMA    OF   THE    LTERUS. 

the  pelvic  wall ;  they  can  best  be  recognized  as  hard  nodules  in  the  soft  cellular 
tissue  by  the  sense  of  touch ;  if  any  are  found,  they  can  be  dissected  out  in 
chains  along  with  the  cellular  tissue. 

The  next  step  is  the  linal  one  in  the  enucleation — the  amputation  of  the 
vaginal  vault  and  the  removal  of  the  uterus  and  as  much  of  the  vagina  as  it  is 
necessary  to  extirpate  with  it.  When  the  carcinoma  affects  the  body  of  the 
uterus  alone  the  vaginal  vault  may  be  opened  at  any  convenient  point  near  the 
cervix.  But  when  the  disease  affects  the  cervix,  then  the  point  of  amputation 
of  the  vagina  must  be  determined  with  great  care  at  the  examination  made  be- 
fore the  operation ;  under  all  circumstances  the  amputation  must  be  made  at 
least  2  centimeters  below  the  lower  margin  of  the  disease.  The  danger  of  leav- 
ing a  considerable  portion  of  a  carcinoma  extending  downward  into  the  vaginal 
epithelium  is  well  shown  in  Fig.  451.  Before  opening  the  vagina  the  posterior 
pelvis  must  be  packed  with  gauze  in  such  a  way  as  to  take  up  at  once  any  dis- 
charges escaping  from  the  wound. 

It  is  my  plan  always  to  determhie  the  exact  position  and  the  limits  of  the 
vagina  by  percussing  it  lightly  with  the  forefinger,  when  it  is  easily  recognized 
by  the  tympanic  sound. 

The  vagina  is  best  opened  first  in  front  with  a  thermo-cautery  knife  at  a  dull 
heat,  l)ecause  this  checks  the  bleeding  from  all  but  the  largest  vessels,  and  so 
saves  a  great  deal  of  time  which  must  otherwise  be  spent  in  encircling  the 
vagina  with  ligatures.  As  rapidly  as  the  vagina  is  cut  through  with  the  cautery 
its  edges  are  grasped  by  artery  forceps,  which  serve  at  the  same  time  to  control 
any  hemorrhage. 

As  soon  as  a  free  opening  is  made  into  the  vagina  a  loose  iodoform-gauze 
pack  is  stuffed  into  it  to  take  up  any  secretions,  and  when  tlie  separation  be- 
tween the  uterus  and  vagina  is  carried  a  little  farther  still,  a  gauze  pad  is  bound 
around  the  cervical  end  of  the  uterus  to  prevent  anv  contamination  of  the  wound 
from  that  source.  Should  there,  however,  be  contamination,  in  spite  of  these 
precautions,  the  operator  must  instantly  take  a  sponge  or  piece  of  gauze  and 
Avipe  off  the  surface  very  carefully  and  thoroughly.  Any  knife  or  other  instru- 
ment used  in  cutting  carcinomatous  tissue  should  be  put  aside  and  not  used  again 
until  sterilized.  The  specimen  removed  should  be  put  into  a  hardening  solution 
at  once  and  carefully  studied,  devoting  particular  attention  to  the  cut  surfaces. 
If  the  disease  extends  right  out  to  the  edge,  the  probability  of  a  rapid  return 
will,  of  course,  be  much  greater. 

The  operator  then  washes  his  hands  thoroughly,  and  proceeds  to  control  the 
vaginal  vessels  by  passing  as  many  catgut  ligatures  as  are  needed  for  the  purpose 
through  the  outer  tissues  of  the  vagina  in  a  direction  perpendicular  to  its  long  axis. 

The  pelvis  is  now  carefully  examined  for  other  enlarged  glands  either  lying 
on  or  under  the  iliac  vessels,  at  the  bifurcation  of  the  common  iliac  artery,  or 
just  above  it.  Wherever  these  are  found  they  should  be  removed.  Enlarged 
glands  lying  upon  the  internal  or  external  iliac  veins  can  often  be  removed  only 
with  extreme  care  and  by  painstaking  dissection.  In  one  instance  I  found  the 
gland  semilunar  in  form  and  closely  pressing  upon  the  external  iliac  vein  whose 


OPERATIOX    FOR   ABDOMIXAL   HYSTETECTOMY    FOR    CAN'CER. 


329 


form  it  bad  taken ;  it  was  only  detached  bv  a  minute  slow  dissection,  but  the 
separation  was  finally  satisfactorily  made.  If  a  vein  is  torn  off  at  its  point  of 
entrance  into  the  external  or  common  iliac  veins  the  opening  should  be  closed 


Fig.  470. — After  freeing  the  Vjladder  and  dissecting  out  the  left  broad  ligament,  the  vaginal  vault  is 
opened  anteriorly  and  all  hemon'hage  controlled  by  a  series  of  sutures  placed  as  shown  in  the  figure.  The 
bladder  and  ureters,  with  bougies,  are  shown  in  dotted  outlines. 


by  a  fine  suture  with  a  fine  needle,  folding  the  wall  of  the  vein  upon  itself,  in 
this  way  avoiding  the  necessity  of  ligating  the  large  trunk  with  the  attendant 
risk  of  gangrene  below  it. 

A  thorough  inspection  of  the  whole  area  exposed  and  of  all  the  ligatures 
applied  to  important  vessels  is  now  made  as  a  distinct  and  most  important  step 
in  the  operation  ;  in  this  inspection  the  operator  should  assure  himself  as  far  as 
possible  as  to  the  thoroughness  with  which  the  disease  has  been  extirpated,  he 
should  discover  any  persistently  bleeding  points  and  control  them  with  liga- 
tures, and,  al)Ove  all,  he  should  see  that  all  the  large  vessels  are  securely  tied  and 
should  reinforce  any  doubtful  ligatures. 

Tlie  anterior  and  posterior  semilunar  lines  of  peritoneum  which  border  the 
wound  area  in  front  and  behind  are  now  brought  together  by  a  continuous  cat- 
gut suture,  beginning  at  the  pelvic  brim  on  one  side  and  extending  down  across 
the  pelvic  floor  and  up  to  the  brim  on  the  opposite  side,  where  the  suture  is  tied. 

If  the  possibility  of  contamination  has  been  excluded  throughout  the  opera- 
tion the  abdominal  incision  may  now  be  closed  by  the  three  layers  of  sutures,  to 
the  peritoneum,  fascia,  and  skin ;  but  whenever  there  lias  been  any  contamina- 


330  ABDOMINAL    HYSTERECTOMY    FOR    CARCIXOMA    OF    THE    UTERI'S. 

tion  from  the  uterus  or  vagina  the  operation  should  not  be  conchided  Avithout 
first  thoroughly  washing  out  the  pelvis  with  normal  salt  solution  with  the  pa- 
tient in  a  horizontal  position. 

A  loose  gauze  pack  is  now  pushed  up  through  the  vagina  and  through  the 
opening  at  its  vault  to  give  support  to  the  peritoneum  and  to  drain  the  wound ; 
at  the  same  time  the  vagina  should  be  loosely  filled  with  a  similar  pack. 


Fig.  471. — Sagittal  Section,  showing  the  Left  Side  of  the  Pelvis,  with  the  Operation  Completed. 

The  anterior  and  posterior  peritoneum  is  united  by  a  continuous  catifut  suture.  The  stump  containing 
the  ovarian  vessels  is  seen  at  tlie  pelvic  brim,  this  is  usually  turned  under  and  concealed  ;  the  sutured  peri- 
toneum above  tliis  has  been  opened  in  order  to  dissect  out  the  enlarged  iliac  glands.  The  vaginal  vault  is 
not  closed,  but  a  gauze  pack  is  placed  in  the  vagina  and  up  under  the  peritoneum. 

Shock  from  the  prolonged  operation  must  be  sedulously  guarded  against  by 
keeping  the  patient  well  wrapped  in  woolens,  and  with  hot-water  bottles  about  her 
during  its  performance,  by  giving  hypodermics  of  strychnin  at  suitable  intervals, 
by  avoiding  all  unnecessary  delay,  so  as  to  make  the  anesthesia  as  short  as  possible, 
and  by  giving  a  hot  stimulating  rectal  enema  just  before  she  goes  off  the  table. 

For  anemia  and  hemorrhage  it  will  be  best  to  infuse  from  500  to  800  cubic 
centimeters  of  normal  salt  solution  into  the  cellular  tissue  under  the  breast,  dur- 
ing or  at  the  close  of  the  operation. 


OPERATION    FOR    ABDOMIXAL    HYSTERECTOMY    FOR    CAXCER. 


VSl 


When  the  operation  is  complicated  by  an  extension  of  tlie  disease  down  the 
anterior  vaginal  wall  or  into  the  base  of  the  bladder,  this  may  be  met  by  a 
wider  excision  at  this  point,  even  cntting  out,  if  need  be,  a  large  part  of  the 
base  of  the  bladder.  After  completing  the  enucleation  tlie  clean-edged  wound 
in  the  bladder  may  then  be  brought  readily  together  by  interrupted  sutures  of 
fine  silk,  passing  through  all  its  Avails  except  the  mucosa.  Care  must  of  course 
be  taken  not  to  injure  the  ureters  at  their  entrance  into  the  bladder.  When  the 
disease  extends  out  laterally  or  posteriorly  onto  the  rectum  farther  than  the  oper- 
ator has  anticipated,  the  extirpation  sometimes  becomes  a  very  difficult  one.  It 
is  particularly  hard  to  make  any  satisfactory  dissection  in  thickened  tissues  about 
the  rectum,  unless  the  patient  happens  to  be  thin  and  the  pelvis  shallow.    When 


^^  ^i^X^r^^J^ 


Fig.  472. — Epithelioma  of  the  Cervix  ix  Grapelike  Mass. 

Sliowing  the  extensive  removal  of  the  uterus  and  broad  ligaments  by  the  abdominal  method.    No.  741. 
natural  size. 


there  is  much  lateral  infiltration  the  embarrassment  from  the  hemorrhaire  in 
cutting  through  the  infiltrated  tissue  is  sometimes  so  great  that  the  operator  has 
to  abandon  all  idea  of  radical  relief,  and  finish  the  operation  the  best  way  he 
can.  I  operated  upon  a  case  of  this  kind  Oct.  16,  1893.  The  patient  (S.  L., 
2248)  had  a  large  friable  carcinoma  of  the  cervix,  but  no  infiltration  of  the 
broad  ligaments  could  be  felt.  On  opening  the  abdomen,  strong  velamentous 
adhesions  from  the  sigmoid  flexure  to  the  posterior  surface  of  the  uterus  were 
freed  by  dissection  with  the  knife,  the  left  ovary  and  tube  were  then  dug  out  of 
a  bed  of  dense  adhesions,  and  the  ovarian  vessels  ligated  and  the  enucleation 
begun.  The  riglit  ovary  was  also  dissected  out  of  a  bed  of  adhesions,  and  the 
rectum  freed  from  adhesions  binding  it  over  the  internal  iliac  artery.  As  the 
o])eration  proceeded,  it  was  found  impossible  to  extirpate  the  disease  in  tlie  broad 
ligaments  and  to  check  the  free  oozing  from  the  diseased  tissue  which  was  cut ; 
in  order,  therefore,  to  conti-ol  the  entire  blood  supply  going  to  the  part,  I  ligated 
both  internal  iliac  arteries  at  a  ])oint  1  centimeter  bel(»w  the  bifurcation  of  the 
common  iliacs.     After  the  ligation  all  pulsation  in  the  pelvis  on   both  sides 


332 


ABDOMIXAL    HYSTEREUTO.M Y    FOR    CARCINOMA    OF   THE    UTERUS. 


ceased  below  the  ligatures.     On  the  left  side  the  ureter  was  iirst  located  and 
draw^n  ujd  and  out  of  the  way  while  the  ligature  was  being  passed.     On  the 

right  side  there  was  a  marked  hydroureter, 
but  I  nicked  the  peritoneum  over  the  ureter 
and  drew  it  out  toward  the  median  line 
while  the  artery  was  being  tied ;    on  con- 


FiG.  473. — -Uterus  Exuci.eated  Per  Vaginam, 
TO  Contrast  with  the  Uterus  Enucle- 
ated FROM  Above,  Fig.  472. 

Showing  the  great  difference  in  the  amount 
of  tissue  removed. 


Fig.  474. — Small  Sarcoma  in  the  Right  Horn  of  the 
Uteri's. 

Diagnosis  made  by  curettauo;  hysterectomy,  the  patient 
living'  without  recurrence  five  years  after  operation. 


tinuins  the  dissection  of  the  diseased  mass  this  ureter  was  liberated  from  a 
bed  of  cancerous  tissue,  involving  its  course  for  5  centimeters.  The  patient 
made  a  good  recovery  and  suffered  in  no  way  from  the  artificial  pelvic  anemia, 
and  the  disease  returned  so  slowly  that  she  lived  over  two  years  after  the 
operation. 

Sarcoma  of  the  Uterus. — Sarcoma  of  the  uterus  is  a  connective  tissue  growth 
of  malignant  type  occurring  at  all  ages. 

For  clinical  convenience,  sarcoma  of  the  uterus  may  l)e  divided  into  sarcoma 
originating  in  the  cervix  and  sarcoma  commencing  in  the  body. 

Sarcoma  of  the  Cervix. — In  rare  instances  this  disease  appears  like  bunches  of 
grapes  springing  from  the  cervix,  as  first  described  by  Spiegelberg  in  1S79,  who 
reported  the  case  of  a  girl  seventeen  years  of  age.  The  anterior  cervical  lip  was 
thickened  and  enlarged,  and  covering  its  margins  and  surface  were  oval,  yel- 
lowish-brown outgrowths,  1  or  2  centimeters  in  length.  These  looked  like 
transparent  cysts,  were  easily  crushed,  and  contained  a  thick,  sticky  fluid.  The 
girl  returned  nine  months  later  with  the  entire  vagina  filled  by  the  growth, 
which  resembled  a  hydatiform  mole.  Weigert,  who  examined  the  tissue  micro- 
scopically, found  these  cystlikc  masses  covered  by  a  single  layer  of  cylindrical 


SARCOMA    OF   THE    CEEYIX. 


333 


epithelium,  and  their  interior  composed  of  large,  round,  sjjindle-shaped  and 
branching  cells,  sejjarated  from  one  another  by  clear  spaces. 

I  have  seen  but  one  similar  case,  in  a  woman  about  thirty  years  of  age, 
where,  springing  from  the  cervix  and  hanging  down  into  and  filling  the  vagina, 
was  a  growth  i-esembling  a  bunch  of  grapes.  In  my  case  amputation  of  the 
cervix  was  followed  by  a  speedy  recurrence,  invasion  of  the  surrounding  tissues, 
and  death. 

Dr.  J.  W.  Williams,  who  has  collected  these  cases,  says  that  in  the  majority 
of  instances  this  variety  of  the  disease  manifests  itself  before  the  twentieth  year 
or  after  the  menopause.     In  only  three  cases  did  it  occur  between  these  periods. 


Fig.  475. — Sarcoma  of  the  Body  of  the  Utekvs. 

The  upper  two  thirds  of  the  uterine  body  is  distended  with  mulberry-shaped  tumor  masses  resembling 
brain  tissue,  and  quite  vascular.  The  line  of  junction  with  the  uterine  wall  appears  sharply  detined,  but 
under  the  microscope  metastatic  nodules  were  found  in  the  lymphatics  of  the  left  uterine  coriui.  San.  204, 
Operation,  April  30, 1895.     No  recurrence,  Feb.,  1S9S.    }4  natural  size. 

Spindle-celled  Sarcoma  of  the  Cervix . — Only  one  case  of  this 
variety  has  come  under  my  notice.  The  patient  was  thirty-eight  years  of  age, 
had  been  married  twenty-one  years,  and  was  the  mother  of  eight  children. 
Four  months  before  admission  she  suddenly  began  to  have  copious  uterine  hem- 
orrhages, which  gradually  ceased,  but  a  watery  discharge  persisted. 

On  vaginal  examination,  the  cervix  was  found  to  be  the  seat  of  a  new 
growth,  which  was  hard,  nodular,  and  filled  the  entire  vaginal  vault.  The  dis- 
ease was  clearly  ineradicable,  but  the  excess  of  tissue  was  curetted  away.  His- 
tological examination  showed  that  it  was  a  large  spindle-celled  sarcoma. 

Endothelioma  of  the  Cervix  . — This  is  an  exceedingly  rare  condi- 
tion, not  more  than  five  or  six  cases  having  been  recorded.  In  all  of  our  cases 
of  maliijnant  growths  of  the  cervix  oidv  one  has  beloiiijed  to  this  ijjroui).  The 
cervix  in  this  case  measured  4*5  X  3.5  centimeters,  and  was  markedly  indurated, 


334: 


ABDOMINAL   HYSTERECTOMY    FOR    CARCINOMA    OF   THE    UTERUS. 


while  the  external  os  was  represented  by  a  craterlike  excavation  2-5  X  2  X  2 
centimeters.  The  floor  of  the  excavation  was  roughened,  but  there  was  no  evi- 
dence of  softening  or  friability  nntil  the  upper  part  of  the  cavity  was  reached. 

On  histological  examination,  the  typical  jDicture  of  an  endothelioma  was 
found. 

Sarcoma  of  the  Body  of  the  Uterus , — This  is  a  rare  disease 
when  compared  wdth  adeno-carcinoma  of  the  uterus,  as  shown  by  Wilhams,  who 
in  1894  was  able  to  collect  but  one  hundred  and  forty-four  cases  from  the  litera- 
ture, including  both  those  arising  from  the  cervix  and  the  body.  These  sarco- 
mata may  be  divided  into  two  groups,  those  affecting  the  mucosa  and  those 
arising  in  the  parenchyma. 

The  growth  usually  springs  from  the  upper  part  of  the  uterine  cavity,  and 
although  it  may  be  diffuse  in  character,  is  usually  sharply  defined.     If  detected 

in  the  early  stage  (see  Fig.  474)  it  may  con- 
sist of  one  rounded  or  oval  nodule,  but  if 
larger  it  may  be  lobulated,  as  is  well  shown 
in  Fig.  475.  On  cutting  the  sarcomatous 
nodule  it  usually  presents  a  smooth,  homo- 
geneous surface  not  often  traversed  by 
broad  trabeculee,  as  seen  in  adeno-carci- 
noma. 

During  the  last  four  years  there  have 
been  three  cases  of  sarcoma  of  the  body 
occurring  in  my  clinic,  two  round-celled 
and  one  spindle-celled  sarcoma. 

Histologically  the  attention  is  at  once 
drawTi  to  the  large  areas  of  the  growth 
showing  practically  no  necrosis  and  per- 
fectly preserved.  The  tissue  is  composed 
of  a  homoo-eneous  mass  of  cells  with  lit- 
tie  intervening  stroma ;  the  cells  have 
round  vesicular  nuclei  and  are  remark- 
ably uniform  in  size  ;  traversing  the  growth 
are  many  delicate  blood  capillaries  which 
ramify  in  all  directions,  dividing  the  tissue 
up  into  alveoli.  If  necrosis  takes  place  it 
is  usually  along  one  margin,  the  underly- 
ing growth  remaining  intact. 

Secondary  Sarcoma  of  the 
Uterus.  —  The  uterus  is  occasionally 
secondarily  involved  by  a  sarcoma  of  the  ovary.  In  1894  I  operated  on  a 
patient  wdiere  there  was  a  large  frial)le  tumor  occupying  the  right  side  of 
the  pelvis;  it  penetrated  the  uterus  and  formed  a  large  mass  in  the  uterine 
cavity,  while  a  portion  of  the  growth  projected  through  the  external  os.  Dr. 
Cullen  examined  this  case  and  found  that  it  was  an  angio-sarcoma  of  the  ovary 


Fio.   471'..  —  Sakcomatois    Nodule    in    the 
Vagina. 

Secondary  to  siireoma  of  the  uterus  and 
right  ovary.  Op.  Feb.  5,  ISOG.  %  natural 
size. 


SAKCUMA    OF    THE    UTERUS. 


335 


See  Johns  Hopk.  Hasp.  Bui.,  Dec, 


with  secondary  involvement  of  the  uterut 
1894. 

A  second  most  instructive  case  occurred  in  1896.  As  seen  from  an  exami- 
nation of  Fig.  476,  a  lobulated  and  smooth  mass  projected  from  the  cervical 
canal,  and  Fig.  478  shows  that  the  uterine  cavity  was  also  tilled  with  large  and 
small  lobules  of  a  new  growth.     Reference  to  Fig.  477  shows  that  the  growth 


Fui.  477. — .Sakcuma  (<v  thk   Uteris  (C)  axi>  Right  Ovarv. 
The  left  ovary  {f>v]  atnl  tube  ( T)  are  intact.     The  right  ovary  i-s  converted  into  a  inas.s  of  large  nodule.s, 
choking  the  pelvis.'covered  by  adhesions,  and  attached  to  the  omentum,  part  of  wJiieli  i.s  left  on  it.     Feb.  5, 
1896.     No.  1054.     1^  natural  s"ize. 

commenced  outside  of  the  uterus,  and  that  this  organ  was  secondarily  involved. 
The  microscopical  examination  demonstrated  that  the  growth  was  a  si)indle- 
celled  sarcoma,  originating  in  the  ovary. 

The  disease  extends  by  contiguity  of  tissue,  by  the  veins,  and  by  the  lym- 
phatics ;  the  extension  is  often  found  in  the  direction  of  the  vagina,  which  then 
contains  a  number  of  bluish  or  reddish  nodules  of  various  sizes. 


336 


ABDOMINAL   HYSTERECTOMY    FOR   CARCINOMA    OF   THE    CERVIX. 


The  tendency  is  to  break  clown  late  and  to  discharge  blood  and  watery  flnid 

with  the  cell  dchris. 

The  diagnosis  is  made  from  a  microscopic  examination  of  scrapmgs  or  ol 
a  piece  cut  out  of  the  tumor.  The  patient  complains  of  discomfort  and  some- 
times of  hemorrhages,  and  on  examination  a  uterine  tumor  is  found  which 
under  the  microscope  proves  to  be  a  sarcoma.  Hemorrhage  is  by  no  means  a 
constant  symptom;  in  one  of  my  cases,  too  far  gone  for  any  operation,  there 
had  never  been  any  hemorrhage  at  all. 

Cachexia  and  pain  are  usually  well  marked  when  the  growth  is  large. 


Fig.  478. — Sarcoma  of  the  Uteri's  (Secoxi' 


OF  THE  Ovary)  cut  open  in  Front. 


The  sarcoma  forms  a  smooth  lobulated  mass  conipletely  flllincr  tlie  uterine  cavity.     Over  many  of  the 
nodules  tlie  mucosa  is  still  preserved.     Feb.  5,  1896.     Path.  No.  1054.     Natural  size. 


In  another  case,  operated  upon  in  1893  and  still  living,  the  patient  had 
frequent  hemorrhages,  and  a  diagnosis  of  sarcoma  was  made  from  curetted 
specimens ;  on  removal,  a  little  tumor,  12  millimeters  in  diameter,  was  found 
in  the  right  uterine  cornu. 

While  the  naked-eye  appearances  are  often  characteristic  they  may  also 
prove  so  deceiving  that  the  microscope  must  be  looked  upon  as  the  one  certain 
means  of  making  a  diagnosis. 

In  one  instance,  for  example,  I  was  in  serious  doubt  whether  the  tumor, 
situated  on  an  inverted  fundus,  was  a  myoma  or  a  sarcoma.  In  general  ap- 
pearance the  tumor  was  slightly  lobulated,  edematous,  friable,  and  without  any 


SARCOMA  OF  THE  UTERUS.  337 

capsule  at  all ;  and  on  detaching  it  from  the  fundus  an  irregular  ragged  base 
was  left  behind.  The  tissue  was  pale  and  waxy  and  tore  in  parallel  striae; 
in  short,  the  tumor  to  the  naked  eye  closely  resembled  a  sarcoma,  but  the  micro- 
scope showed  that  it  was  an  edematous  myoma. 

The  operation  for  the  extirpation  of  a  sarcomatous  uterus  consists  in  a  wide 
enucleation,  the  same  as  that  for  carcinoma  just  described. 


CHAPTEK    XXXI. 

MYOMECTOMY— HYSTERO-MYOMECTOMY. 

1.  Definition. 

2.  Clinical  characters  of  fibroid  tumors. 

3.  Kinds  and  sites  of  myomata.     1.  Submucous.     3.  Interstitial,  or  intramural.     3.  Subserous,  or 

subperitoneal.    4.  Fibro-cystic  tumors. 

4.  Form  peculiarities. 

5.  Diagnosis.     Examination,  under  anesthesia,  if  the  tumor  is  small ;  sounding  the  length  of  the 

uterine  cavity. 

6.  Palliative  treatment.      1.  Relief  of  pressure  symptoms.     2.  Hemorrhage:   a.  Curettage,     b. 

Galvanism. 

7.  Indications  for  abdominal  operations  upon  the  myomatous  uterus. 

8.  Myomectomy.     1.  Definition.     2,  Cases  suitable  for.     a.  In  general,  always  the  operation  of 

election  in  young  women,  in  the  absence  of  other  complications,  b.  In  particular.  (1)  All 
pedunculate  myomata,  where  the  removal  of  the  tumor  will  leave  a  normal  uterus.  (2) 
All  subserous  or  interstitial  tumors  which  are  well  defined  in  relation  to  the  body  of  the 
uterus,  whether  single  or  multiple.  (3)  Multiple  small  myoma.  (4)  Broad  ligament  my- 
omata where  the  tubes  and  ovaries  are  not  diseased.  (5)  Cornual  myomata.  (6)  Submucous 
myomata  too  large  to  take  out  per  caginam.  3.  Operation :  a.  Exposure  of  tumor,  b. 
Incision  of  capsule  or  pedicle,  c.  Temporary  control  of  hemorrhage,  d.  Enucleation,  e. 
Permanent  control  of  hemorrhage — ligature  and  suture.  /.  Closure  of  incision,  suturing 
the  angles,  g.  Closure  of  abdominal  incision  without  a  drain,  h.  Dangers  of  the  opera- 
tion— hemorrhage  and  sepsis.  4.  Pedunculate  myomata.  5.  Subserous,  sessile,  and  inter- 
stitial myomata.  a.  Removal  of  large  interstitial  myoma  without  sacrificing  any  uterine 
tissue,  o.  Eight  subserous  and  interstitial  myoma  removed  by  seven  separate  incisions. 
c.  Cornual  myoma.     6.  Extirpation  of  submucous  myomata  per  abdomen. 

9.  Ilystero-myomectomy.      1.   Indications  for.      2.   Operation :  a.   Preliminary  preparation,     b. 

Opening  abdomen,  c.  Delivering  tumor,  cl.  Ligation  of  left  ovarian  vessels  and  left 
round  ligament,  e.  Detachment  of  the  vesico-uterine  fold  from  side  to  side,  and  pushing 
it  down,  separating  bladder  from  cervix.  /.  Ligation  of  left  uterine  vessels,  g.  Amputa- 
tion of  uterus  in  cervical  portion,  leaving  a  cup-shaped  pedicle.  //.  Clamping  uterine 
artery  of  right  side,  clamping  right  round  ligament,  clamping  right  ovarian  vessels,  fol- 
lowed by  removal  of  tumors,  i.  Application  of  ligatures  in  place  of  forceps.  /.  Suturing 
the  stump,  k.  Covering  wound  area  with  vesical  peritoneum.  I.  Cleansing  peritoneal 
cavity,  m.  Closure  of  abdomen  without  drain. 
10.  Compiications  of  hystero-myomectomy.  1.  Complications  due  to  adhesions  and  affections  of 
surrounding  structures,  a.  Inflammatory.  (1)  Simple  adhesions  of  tubes  and  ovaries.  (2) 
Hydrosalpinx.  (3)  Pyosalpinx  and  abscess  of  ovary.  (4)  Encysted  peritonitis.  (5)  Omental 
adhesions.  (6)  Parietal  adhesions.  (7)  Adhesions  to  rectum,  sigmoid,  colon,  and  small  in- 
testines. (8)  Adhesions  to  vermiform  appendix.  (9)  Adhesions  to  liver  and  suspensory 
ligament,  b.  Tumors  of  the  ovary.  (10)  Ovarian  cystomata.  (11)  Dermoid  cysts.  (12)  Fi- 
broid ovary.  (13)  Ovarian  hydrocele.  (14)  Ovarian  hematoma.  (15)  Carcinoma  of  the 
ovary,  c.  Diseases  of  the  cervix  and  uterine  mucosa.  (16)  Cancer  of  the  cervix.  (17)  Can- 
cer of  the  uterus  associated  with  myoma.  (18)  Tuberculosis  of  the  endometrium.  2.  Com- 
plications due  to  changes  in  the  tumors  themselves.  (19)  Cysto-myoma.  (20)  Telangiectatic 
myoma.  (21)  Suppurating  myoma.  (22)  Cystic  myoma,  with  twisted  pedicle.  (23)  Adeno- 
myoma  uteri  diffusura  benignum.  3.  Complications  due  to  location  of  tumors.  (24)  Ele- 
vation of  tubes  and  ovaries  high  out  of  pelvis.  (25)  Globular  myoma  filling  pelvis.  (26) 
Myomata  wedged  in  pelvis.  (27)  Myoma  below  vesical  peritoneum.  (28)  Myoma  l^elow  pos- 
terior pelvic  peritoneum.  (29)  Myoma  in  upper  part  of  broad  ligament.  (30)  Myoma  in 
broad  ligament  proper.  (31)  jMyoma  developed  antero-laterally,  twisting  uterus.  (32) 
Myoma  developed  postero-laterally.  (33)  Myomata  developing  under  the  pelvic  peritoneum 
in  several  of  these  positions  at  once.  (34). Myomata  displacing  the  ureters  upward.  4. 
Complications  due  to  pregnancy,  ascites,  and  other  causes.  (35)  Myoma  witii  pregnancy. 
(36)  Myoma  simulating  pregnancy.     (37)  Myoma  and  ascites,  feeble  heart,  nephritis,  etc. 

Definition . — Myoma  of  the  uterus,  fibroid  tumor  or  fibro-mjoma  of  the 
uterus,  is  an  atypical  nodular  growth  springing  from  some  portion  of  the  uterine 

338 


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HYSTEBO-lVi 


DESCRIPTION  OF  PLATE  XIX. 

INJECTED  SPECIMEN    SHOWING  THE  VASCULAR    SUPPLY  OF  MYOMATA — SUBMUCOUS, 
INTERSTITIAL,   AND   SUBSEROUS. 

The  tumors  are  enibedded  in  a  vascular  hypertrophied  uterus  which  is  deeply 
injected.  The  pedunculate  subserous  tumor  above,  which  has  been  divided,  shows  a 
tessellated  arrangement  of  tlie  large  injected  vessels  surrounding  its  base ;  on  the  left 
side  the  vessels  are  seen  penetrating  tlie  substance  of  the  tumor  between  its  lobules ; 
the  distal  portion  is  anemic.  The  large  interstitial  tumor  is  seen  everywhere  pene- 
trated by  small  capillaries,  and  there  are  a  few  lai-ge  vessels  near  the  outer  margin  and 
the  center.  There  is  a  remarkable  contrast  between  the  vascular  supply  of  the  uterus 
and  that  of  the  tumor  which  is  partially  submucous.  The  uterine  cavity  is  further 
occupied  by  sessile  and  pedunculate  submucous  tumore,  each  of  which  shows  a  beau- 
tiful vascular  corona;  on  the  free  surface  of  the  upper  tumor  there  is  a  leash  of  lai'ge 
vessels.  The  atrophy  of  the  nducous  membrane  over  these  gi'owths  is  in  contrast  with 
the  unaltered  mucosa  of  the  rest  of  the  uterus.  Specimen  injected  by  Dr.  J.  G.  Clark 
to  demonstrate  the  source  of  hemorrhages  from  the  uterine  mucosa. 


PLATE  XIX 


r.l!liLPnin(tiCo' 


CLINICAL    CHARACTERS    OF    FIBROID    TUMORS.  339 

body,  usually  above  the  cervix,  varying  in  size  from  a  microscopic  node  to  tliat 
of  a  mass  or  masses  choking  the  whole  abdominal  cavity.  The  tumor  is  made 
up  of  a  disorderly  interlacement  of  muscular  and  connective-tissue  fibers,  in  the 
larger  masses  grouped  into  more  or  less  well-defined  spherical  nodules. 

Between  the  groups  of  fibers  run  arteries,  veins,  and  lymph  channels  derived 
from  the  normal  vessels  of  the  uterus,  ramifying  at  first  beneath  the  capsule  of 
the  tumor  and  then  plunging  directl}^  into  its  interior.  Isolated  tumors  within 
the  uterine  walls  are  well  circumscribed  and  surrounded  by  the  normal  muscular 
fibers ;  tumors  projecting  through  the  muscular  wall  become  covered  on  the 
uterine  side  by  the  mucosa,  and  on  the  abdominal  side  by  peritoneum. 

Clinical  Characters  of  Fibroid  Tumors. — Although  all  myomata  probably  exist 
in  fetal  life  in  diminutive  form,  they  rarely  give  evidence  of  their  presence  until 
menstruation  has  been  established  for  some  years.  Marked  indications  of  their 
existence  usually  occur  about  middle  life,  from  thirty -five,  with  increasing  fre- 
quency, up  to  forty -five  years  of  age. 

The  earliest  clinical  signs  are  painful  menstruation,  excessive  at  the  men- 
strual period,  and  in  married  women  sterility,  and  repeated  early  miscarriages. 

The  tumors,  at  first  occupying  the  pelvis,  as  they  grow  extend  toward  the 
abdomen,  and  growing  slowly  do  not  as  a  rule  attract  attention  by  their  size 
until  they  have  exceeded  the  capacity  of  the  pelvis,  and  occasion  a  symmetrical 
or  nodular  enlargement  of  the  lower  abdomen  evident  upon  inspection,  and  still 
more  upon  palpation. 

The  rate  of  growth  is  variable ;  it  is  sometimes  so  slow  as  to  require 
ten,  fifteen,  and  twenty  years  before  the  tumor  attains  the  size  of  a  uterus  at 
term.  Some  of  the  more  vascular  myomata,  however,  may  even  develop  per- 
ceptibly within  a  few  months. 

"With  the  development  of  the  tumors  there  is  often  an  enormous  hypertro- 
phy of  the  enveloping  uterine  muscle ;  for  example,  in  one  case  the  tumors 
weighed  1,950  grams  and  the  uterus  alone,  after  they  were  removed,  weighed 
625  grams. 

Profuse  menstrual  hemorrhage  is  the  commonest  as  well  as  the 
most  striking  symptom,  and  occurs  in  about  fifty  per  cent  of  the  cases.  At  the 
beginning  it  is  apt  to  be  confined  to  an  excessive  flow  at  the  period,  which  lasts 
from  five  to  eight  days ;  although  this  weakens  the  patient  at  the  time,  it  is  readily 
compensated  for  in  the  interim  ;  later,  as  the  tumor  enlarges,  the  fiow  is  of  longer 
duration  and  becomes  more  excessive  in  quantity.  By  this  time  menstruation, 
which  has  been  regular  although  excessive,  becomes  more  frequent,  appearing 
every  three  or  even  every  two  weeks,  and  leaves  the  patient  prostrated  from  exces- 
sive loss  of  blood.  The  most  profound  anemia  from  this  cause  is  not  uncommon  J 
the  patient's  skin  becomes  peculiarly  transparent,  of  a  waxy  yellow  hue,  and  she 
suffers  from  dyspnea,  epistaxis,  and  palpitation,  with  a  sense  of  utter  weakness. 
A  distinct  anemic  heart  murmur  marks  the  profound  changes  in  the  condition  of 
the  blood. 

Pain  is  a  variable  symptom  ;  it  is  most  marked  when  the  uterus  contains  a 
number  of  smaller  myomatous  masses  distributed  throughout  its  walls,  when 


340 


MYOMECTOMY — HYSTERO-MYOMECTOMY, 


it  is  usually  menstrual  in  type  and  of    a  distressing,  grinding,  bearing-down 
character,  often  likened  to  severe  protracted  labor  pains. 

Disease  of  the  ovaries  and  tubes  is  frequently  associated  with 
myoma  of  the  uterus,  and  both  ovaries  and  tubes  are  often  found  bound  down 
in  the  pelvis  by  old  inflammatory  adhesions  ;  in  this  way  hydrosalpinx  and  pyo- 
salpinx  are  found.  This  associated  inflammatory  disease  is  often  present  in  con- 
nection with  small  tumors,  w^hen  the  pain  is  doubtless  due  more  to  the  inflamma- 
tion and  the  tugging  on  the  adhesions  than  to  the  presence  of  the  tumors. 


Fig.  47'J. — Greatly  Enlarged  Eight  Ovary  removed  with  a  Myomatous  Uterus  which  was  the  Size 

OF  A  Man's  Head. 

At  both  poles  are  some  lartre  unruptured  cysts,  and  in  between  a  mass  of  thick  cirrhotic  ovarian  tissue. 
B.,  Dec.  6,  1897.     Natural  size^ 

Tlie  ovaries  found  in  connection  with  large  myomatous  uteri  often  undergo 
remarkable  changes  which  can  scarcely  be  called  disease,  although  considered 
by  Virchow  and  others  as  examples  of  interstitial  oophoritis  and  cys- 
tic degeneration. 

These  ovaries  are  for  the  most  part  larger  than  normal,  sometimes  peculiarly 
long  and  flat ;  a  part  of  tlie  increase  in  size  is  often  due  to  the  presence  of  a 
number  of  large  unruptured  follicles.     There  is  an  increase  in  the  number  of 


KINDS    AND    SITES    OF    MYOMATA.  341 

the  corpora  albicantia,  witli  increase  in  the  vascularity  and  thickening  of  the 
vessel  walls. 

Popow  has  shown  that  the  changes  affect  the  albuginea  (surface  of  the  ovarv), 
the  interstitial  tissue  of  the  ovary,  and  the  paranchyma  (follicles).  The  inter- 
stitial tissue  undergoes  a  marked  proliferation,  evident  in  the  coarse  hypertrophy 
of  the  ovary ;  the  follicles  are  most  numerous  in  some  cases  and  then  atrophy 
(oophoritisfollicularis). 

A  typical  example  of  these  changes  seen  in  an  advanced  form  is  shown  in 
Fie:.  479,  removed  with  a  laro-e  mvomatous  uterus. 

Pressure  s  y  m  p  t  o  m  s  do  not  often  occur  until  the  tumors  are  large 
enough  to  choke  the  pelvis,  when  frequent  urination  and  difficult  defecation  are 
common.  AYhen  a  growing  tumor  becomes  incarcerated  under  the  promontory 
of  the  sacrum,  preventing  its  escape  into  the  abdomen,  these  j)ressure  symptoms 
often  become  extremely  urgent.  The  examiner  must,  however,  always  be  on  his 
guard  against  drawing  hasty  conclusions  from  the  size  and  position  of  the  tumor, 
for  it  is  remarkable  how  well  the  rectum  is  able  to  maintain  a  patulous  chan- 
nel under  these  circumstances.  The  bladder  j)reserves  its  function  by  displace- 
ment expanding  upward  into  the  lower  abdomen,  and  becoming  an  abdominal 
organ. 

One  of  the  serious  dangers  arising  from  the  presence  of  the  larger  myomata 
filling  the  abdomen,  more  particularly  if  they  are  developed  under  the  pelvic 
peritoneum,  is  the  production  of  a  hydroureter  by  pressure  at  the  brim, 
impairing  the  function  of  the  kidneys,  and  inducing  hydronephrosis.  In 
a  series  of  one  hundred  hystero-myomectomies  in  my  clinic,  two  cases  were 
operated  upon  on  account  of  periodical  attacks  of  urinary  suppression  due  to 
pressure  on  the  ureters. 

I  have  seen  three  cases  of  py  elonephrosis  associated  with  myomatous 
uteri  where  the  disease  was  probably  grafted  onto  a  hydronephrosis  produced  by 
pressure. 

Cancer  of  the  uterus  complicating  myoma  is  rare,  the  malignant  dis- 
ease starting  on  the  uterine  mucosa  and  extending  from  that  point  into  the  myo- 
matous mass.  The  malignant  growth  may  start  either  in  the  cervical  or  in  the 
corporeal  part  of  the  uterus. 

Kinds  and  Sites  of  Myomata.— One  of  the  most  striking  and  characteristic  dif- 
ferences among  myomata  is  the  variation  in  size.  All  gradations  are  found,  from 
one  the  size  of  a  pin  head  to  a  mass  weighing  over  a  hundred  pounds. 

The  terms  large  and  small  may  be  used  in  a  purely  relative  sense  with  re- 
gard to  the  environment  of  the  tumor ;  for  example,  we  may  speak  of  a  uterus 
not  larger  than  a  fist  as  a  small  myomatous  uterus,  but  when  it  is  big  enough 
to  choke  the  pelvis  and  gets  wedged  in  there  it  is  relatively  large ;  if  the  same 
uterus  escapes  into  the  abdomen  it  is  small  in  relation  to  its  surroundings,  until 
it  attains  the  size  of  a  seven  or  eight  months'  pregnancy,  and  begins  to  encroach 
upon  the  abdominal  viscera. 

The  mechanical  symptoms  produced  by  the  smaller  tumors  are  due  to  pres- 
sure on  various  pelvic  organs,  while  the  large  tumors  (.»ften  become  inconvenient 


3i2 


MYOMECTOMY — HYSTEKO-M  YOMECTOM Y. 


from  their  size  and  weight  alone,  and  in  addition  derange  digestion,  deform  the 
thorax,  cause  diffienlty  in  respiration,  and  interference  with  the  circulation. 

According  to  the  site  of  the  tumor  relative  to  the  uterine  wall,  myomata 
have  long  heen  classified  as  submucons,  interstitial  or  iutranniral,  subserous 
or  subperitoneal.  From  a  practical  standpoint  it  is  important  to  distinguish 
these  forms,  because  each  is  susceptible  of  a  different  mode  of  treatment. 

Submucous  myomata  project  into  the  uterine  cavity  and  are  covered 
over  the  greater  part  of  their  periphery  with  the  uterine  nnicous  membrane. 
As  a  result  of  the  growth  of  the  tumor  in  this  direction  the  uterine  cavity  be- 
comes proportionately  enlarged  either  in  its  transverse  or  in  its  long  axis. 


Fig.  480. — Uterus  with  Extensive  Myomatots  Involvement  chiefly  Interstitial  and  Submucous. 

Note  the  extreme  distortion  of  the  uterine  cavity.    Hystero-myoinectomy.    Kecovery.    H.  G.,  March  21, 
1894.    X  natural  size. 


Interstitial  or  intramural  tumors,  situated  entirely  within  the 
uterine  wall,  are  enveloped  on  all  sides  by  normal  uterine  fibers.  This  form  is 
most  apt  to  become  subperitoneal  as  it  grows. 

Subserous  or  s u  1) p e r i t o n e a  1  tumors  develoj?  in  the  direction  of 
the  abdominal  cavity  and  are  enveloped  for  the  most  part  l»y  the  pertoneum. 
Both  the  subserous  and  the  submucous  myomata  grow  toward  the  surface  and 
tend  to  become  more  polypoid.  The  submucous  tumors  may  be  finally  cast  off 
through  the  cervix  into  the  vagina,  while  the  subserous  narrow  their  attach- 
ments down  to  a  thin  pedicle  and  often  derive  their  nutriment  from  adhesions 
to  other  organs. 


KINDS    AND    SITES    OF    MYOMATA. 


343 


F  i  b  r  o  -  c  V  s  t  i  c  tumors  are  cliaracterized  by  au  excess  of  fluid  elements, 
rendering  them  soft  or  even  fluctuant.  This  fluid,  analogous  to  serum,  is  lield 
in  enormously  dilated  lympli  channels  within  the  tumor.  It  coagulates  spon- 
taneously on  exposure  to  the  air,  a  clinical  feature  recognized  by  the  older 
writers,  and  considered  by  them  pathognomonic  of  this  variety.  This  fact,  how- 
ever, is  unreliable,  because  the  fluid  of  a  tubercular  peritonitis  or  of  a  cystic 
Graafian  follicle  may  also  coagulate  on  exposure.  If  not  extirpated  early  these 
tumors  often  attain  an  enormous  size,  larger  than  any  other  abdominal  growth- 
In  one  case  reported  the  mass  reached  the  enormous  weight  of  195  pounds. 
Usually  the  outer  covering  of  the  tumor,  or  of  each  of  the  individual  compo- 
nent masses,  is  formed  of  dense  myomatous  tissue. 


Fig.  481. — Myom.vtoi's  Tteuus,  showing  Interstiti.vl  and  SfBPEUiTONEAL  Ma.sses. 

The  subperitoneal  tumor  is  half  concealed  behind  the  opened  cervix.  Note  the  large  uterine  cavity  with  a 
smooth  surface  presenting  a  number  of  translucent  vesicles  in  the  lower  portion,  and  on  the  lower  border  of 
the  mucous  polyp  lying  within  the  uterine  cavity.  Note  also  the  large  vessels  laid  open  opposite  the  inter- 
nal OS  uteri.    I'ath.'No^  325.    Y?  natural  size. 

The  life  history  of  a  myomatous  t  u  m  o  r  is  well  illustrated  by  a 
case  which  was  followed  for  twenty-seven  years,  from  the  time  it  was  first  ob- 
served to  the  operation  which  I  performed  in  May,  1894. 

The  patient  (J.  S.  S.,  San.  107),  the  daughter  of  a  prominent  physician,  dis- 
covered an  abdominal  tumor  in  1867  when  in  her  twenty-seventh  year.  Two 
years  later  she  was  examined  by  Dr.  Washington  L.  Atlee,  who  left  the  follow- 
ing notes  and  drawing  of  the  relations  of  the  tumor  to  the  uterus,  for  which  1 
am  indebted  to  his  son-in-law,  Dr.  J.  M.  Drysdale,  of  Philadelphia. 


"  To-dav  I  examined   Miss 


Norfolk,  Va.,  June  24,  1869. 
She  is  as  larc-e  as  a  ladv  seven  months 


advanced,  shape  uniform,  tumor  round  and  prominent,  hard,  nou -clastic,  mov- 
able, not  sensitive,  extends  across  both  hip  bones  and  upward  to  tlie  hypochon- 
04 


344 


MYOMECTOMY — H  YSTERO-M  YOMECTOMY'. 


dria.  The  superior  strait  of  the  pelvis  is  occupied  by  the  same  tumor,  and  in 
the  posterior  part  the  cervix  uteri  is  felt.  It  is  shortened  in  length,  folded 
against  the  tumor  in  front,  soft.  The  sound  enters  to  the  distance  of  eight  or 
nine  inches. 

"  The  following  diagrams  will  explain  things"  (see  Fig.  482)  : 

When  I  saw  the  patient  in  May,  1894,  twenty-five  years  later,  the  abdomen 
was  enormously  distended  by  a  great  symmetrically  disposed  tumor,  the  top  of 
which  was  48  centimeters  (19  inches)  from  the  level  of  the  bed  as  she  lay  on  her 

back.  .  Her  circumference  at 
the  umbilicus  was  128  centi- 
meters (51  inches)  and  she 
measured  114  centimeters  (45 
inches)  from  umbilicus  to  en- 
siform  cartilage.  Ascitic  fluid 
was  felt  in  the  flanks.  She 
had  an  umbilical  hernia  with 
an  opening  6  by  7  centimeters 
(2^  by  3  inches),  and  a  tender, 
round  mass  under  the  right 
ribs  which  was  a  distended 
gall  bladder.  She  was  suffer- 
ing acutely  with  renal  colic 
due  to  suppression  of  the  urine 
from  pressure  on  the  ureters. 

At  the  operation,  May  12, 
the  small  uterus  was  found 
crowded  down  on  the  pelvic 
floor,  and  the  enormous  fibroid  mass,  weighing  59  pounds,  was  attached  to  the 
anterior  uterine  wall  by  a  pedicle  1  centimeter  long  and  3  by  2  centimeters  broad, 
nourished  by  three  enormous  arteries  ^  centimeter  in  diameter,  coursing  super- 
ficially over  the  anterior  part  of  the  fundus. 

The  tumor  was  extirpated  after  a  long  and  difficult  operation,  on  account  of 
the  numerous  vascular  ventral  adhesions.  The  gall  bladder  was  also  opened 
and  a  quantity  of  pus  evacuated. 

She  made  an  uninterrupted  recovery  and  is  now  living  in  perfect  health. 
The  great  interest  attached  to  this  case  is  the  entire  change  in  position 
assumed  by  a  tumor  already  of  great  size. 

Dr.  Atlee's  record  shows  that  in  1869  the  tumor  involved  the  whole  body  of 
the  uterus,  lengthening  out  its  cavity  9  inches.  When  I  examined  it,  twenty - 
five  years  after,  in  spite  of  its  immense  size,  it  had  become  extruded  from  the 
grasp  of  the  uterine  muscular  tissue,  and  was  so  far  detached  from  its  broad 
base  as  to  be  left  with  a  comparatively  small  pedicle. 

Broad-ligament  myomata  develop  from  the  lateral  wall  of  the 
uterus  out  between  the  anterior  and  posterior  layers  of  the  broad  ligament  and 


Fio.  482. — These  diagrams  are  copies  of  sketches  made  by 
Dr.  Washington  L.  Atlee  in  1869.  It  is  important  to  note  the 
length  of  the  uterine  cavity  and  the  intimate  relations  of  the 
myoma  with  the  uterine  walls.  When  seen  by  me  twenty-tive 
years  later,  the  uterus  was  of  normal  size,  and  the  enormous 
tumor  was  attached  to  the  fundus  by  a  pedicle  1  centimeter  long. 


KIXDS    AXD    SITES    OF    MYOMATA. 


34:5 


extend  down  toward  the  pelvic  floor,  and  are  in  reality  a  variety  of  the  sub- 
serous form. 

When  pedunculated,  the  myomata  vary  in  size  from  small  polyps  all 
the  way  to  huge  tumor  masses,  either  submucous  or  subserous.  The  pedicle 
may  even  be  several  inches  long,  but  in  the  subserous  form  it  is  rarely  over  half 
an  inch  in  length. 

Sessile  tumors  have  a  broad  flat  base,  often  with  more  than  half  the 
growth  projecting  into  the  uterine  or  into  the  peritoneal  cavity. 

The  number  of  myomata  found  in  one  uterus  varies  from  a  single 
one  or  several  to  an  indefinite  number,  when  the  uterine  tissue  is  converted  into 
a  myomatous  mass,  consisting  of  a  great  number  of  small  nodules. 

From  a  practical  standpoint  the  exact  location  of  single  tumors,  whether 
cervical  or  corporeal,  is  important.  With  few  exceptions  it  is  the  fleshy  body 
of  the  uterus  above  the  neck  alone  which  is  involved.     When  both  body  and 


Fig.  483.— Globular  Myomatous  Uterus  pkesentino  Form  of  pregnant  Uterus  at  Term,  with  Adap- 
tation OF  THE  Lower  Part  of  its  Form  to  that  of  the  I'elvic  Cavity. 
,    .  The  lower  part  of  the  tumor  is  subperitoneal,  and  the  cervix  is  displaced  up  to  the  level  of  the  pelvic 
brim.     1  wo  peritoneal  adhesions  are  shown  above  the  cervical  opening.     Seen  from  behind.    Ilvstero-myo- 
niectomy.     Keeovery.     Path.  No.  325.    )^  natural  size.  i         »  j  j 

cervix  are  involved,  the  vaginal  portion  of  the  cervix  is  distorted  and  partially 
or  even  entirely  obliterated,  being  represented  by  a  mere  dimple  on  the  vagi- 
nal wall. 

Parasitic   myomata   are  usually  pedunculated  and  depend  for  a  part 
or  the  whole  of  their  blood  supply  upon  adventitious  vessels  of  the  adjacent 


34(] 


MYOMECTOMY — IIYSTERO-MYOMECTOMY. 


organs.  Such  tumors  are  generally  large  abdominal  growths,  either  entirely 
detached  from  the  uterus,  or  connected  with  it  by  a  small  pedicle  only,  while 
they  are  intimately  attached  to  the  abdominal  walls,  intestines,  or  omentum. 
Tumors  with  omental  attachments  present  the  most  striking  characteristics  of 
this  group  ;  the  omentum  forms  a  fringe  around  the  upper  border  of  the  mass, 
and  its  congested  and  tortuous  blood  vessels  are  enlarged  to  the  size  of  goose 
quills,  looking  like  a  cluster  of  whip  cords  or  a  collection  of  angleworms  in  the 
space  between  the  tumor  and  the  transverse  colon. 

Form  Peculiarities . — When  unrestrained  in  its  growth  a  single 
myoma  will  assume  a  more  or  less  spherical  form,  and  retain  it  until  outside 
influences  compel  a  change.  Various  restricting  influences  frequently  impress 
other  than  a  spherical  form  upon  these  tumors.  Two  sets  of  external  forces 
come  into  play  in  this  molding  process,  the  hard  and  the  soft  parts.  Irregular 
tumor  outlines  arising  from  forces  within  the  tumor  itself  are  found  when 
there  is  a  coincident  development  of  a  number  of  these  tumors,  and  when  fresh 


Fig.  484. — JSIyomatous  Uterus,  exhibiting  a  Perfect  Cast  of  the  Pelvis. 

A  rubber  ligature  liiis  been  tlirown  around  the  neck  of  the  mass  and  tied  to  control  the  circulation,  a  pro- 
cedure no  longer  employed.  The  uppermost  part  of  the  mass  in  the  picture  lay  in  contact  with  the  pelvic 
floor,  tlie  tumor  has  therefore  been  inverted  in  lifting  it  out.  It  is  evident  that  the  large  upper  tumor  forms 
a  perfect  cast  of  the  sacral  curve  and  the  posterior  pelvis.  Note  the  irregular  masses,  in  contact  with  the  ab- 
tlomen  just  above  tlie  rubber  tube,  which  projected  out  of  the  pelvis  into  the  abdomen.  Ilystero-myomec- 
tomy.     Kecovery.     Oct.  12,  1892. 

nodules  bud  out  on  the  surface  of  a  tumor,  in  which  case  the  tumor  presents  a 
lobulated  or  bossed  appearance. 

The  most  striking  instances  of  the  plastic  influence  of  repeated  impacts  of 
the  soft  pai-ts  is  represented  by  the  vertical  furrows  on  large  tumors  due  to  the 
pressure  of  the  linea  alba.  The  persistence  with  which  the  rectum  preserves  a 
patulous  channel  when  the  pelvis  appears  to  be  completely  choked  is  an  exam- 


KINDS    AND    SITES    OF    MYOMATA. 


347 


pie  of  tlie  power  of  a  weak  force  acting  witli  persistent  regularity  on  a  more  or 
less  resisting  body. 

A  myoma  is  occasionally  detained  witliin  the  bony  pelvis  until  its  cavity  is 
choked  with  the  tumor,  which  then  presents  a  perfect  cast  of  the  posterior  part 


Fir.  4S5. — Large  Subperitoneal  Myoma,  seen  from  Behind. 

Sliowinjj  remarkable  adaptation  of  form  to  the  vertebral  eolumii.  FU,  the  fundus  of  the  uterus  lay  on 
the  sacral  promontory,  and  the  mass,  T^  below,  lay  on  the  pelvic  tloor,  while  T,  above,  lay  on  tiie  luiiibar 
vertebrte.  From  T  to  F(/,  to  T,  the  form  of  the  tumor  is  concave,  exactly  followinir  the  vertebral  column 
down  to  the  pelvic  lloor.  The  lar^e  tumor  is  also  exactly  adapted  in  its  form  to  the  lumbar  vertebra'  from 
side  to  side ;  its  concavity  thus  presents  a  perfect  cast  of  the  luml)ar  vertebral  bodies  and  the  sacral  promon- 
tory.    Hystero-myomectomy.     Recovery.     Path.  Iso.  498.     ^|^  natural  size. 


of  the  pelvis,  showing  exquisitely  the  sacral  curve  and  the  breadth  of  the  pelvis. 
The  surface  appears  smooth,  but,  if  examined  minutely,  slight  irregularities  due 
to  suppressed  budding  tumors  are  evident.  This  explanation  is  borne  out  by 
the  fact  that  clusters  of  large  spherical  nodules  often  bud  out  through  the  supe- 
rioi-  straight  from  the  main  body  of  the  tumor. 

Another  remarkable  evidence  of  the  conformation  of  myomatous  tumors 
to  their  environment  is  seen  in  the  adaptation  of  some  of  the  larger  tumors 
to  the  sacral  promontory  and  the  projecting  bodies  of  the  lumbar  vertebrre  (see 
Fig.  485). 


348  MYOMECTOMY — HYSTEKO-MYOMECTOMY. 

Diagnosis. — When  a  patieut  complains  of  painful  menstruation, 
becoming  ]y  r  o  f  u  s  e  and  protracted,  and  has  a  history  of  sterility  or 
earlv  miscarriages,  myoma  may  be  suspected.  A  direct  examina- 
tion to  determine  the  size  and  shape  of  the  uterus  is, 
however,  the  only  reliable  means  of  deciding  the  nature 
of  the  disease,  and  in  order  to  detect  and  locate  accu- 
rately small  tumors,  it  is  necessary  to  examine  the  pa- 
tient under  an  anesthetic.  The  inferior  lip  of  the  cervix  is  caught 
with  a  corrugated  tenaculum  or  with  bullet  forceps,  and  while  making  traction 
to  draw  the  uterus  down  toward  the  outlet  the  index  finger  is  carried  high  up 
in  the  rectum  above  the  ampulla.  Tumors  of  small  size  are  felt  as  little  nodules 
or  distinct  rounded  elevations  on  the  ventral  or  dorsal  surfaces  of  the  womb.  I 
have  thus  repeatedly  detected  myomata  of  less  than  a  half  centimeter  in  diam- 
eter high  up  on  the  fundus. 

I  recall  one  case  which  had  been  treated  symptomatically  twenty-fi^■e  years 
for  dysmenorrhea  and  nothing  abnormal  was  detected  ;  when,  however,  the 
examination  was  made  under  anesthesia  j)er  rectum,  the  uterus  was  found  to 
be  full  of  little  myomata. 

When  the  tumor  occupies  the  lower  abdomen  or  fills  a 
large  part  of  the  abdominal  cavity,  more  distinct  diagnostic  signs  are  observed. 
The  abdomen  may  have  an  irregular  nodular  appearance  which  is  quite  charac- 
teristic (see  Vol.  I,  Fig.  57),  or  if  the  tumor  is  a  symmetrical  spherical  mass,  it 
often  closely  simulates  a  pregnant  uterus  (see  Fig.  483;  also  A"ol.  I,  Fig.  55).  In 
such  a  case  the  history  of  the  long  continuance  of  the  growth,  often  over  a 
period  of  many  years,  must  be  considered  in  connection  %vith  the  digital  exami- 
nation in  making  a  diagnosis.  One  strong  peculiarity  often  present  in  these 
myomata  is  the  sharp  contour  made  by  the  upper  border  of  the  tumor  as  it 
drops  to  the  chest  level  with  the  patient  in  the  dorsal  position.  The  resistance 
of  most  myomata  to  palpation  is  characteristic — they  give  the  sensation  of  dense 
hard  unyielding  masses  ;  in  exceptional  cases,  however,  all  the  gradations  are 
found  from  the  puttylike  through  the  soft  vascular  to  the  fluctuating  cystic 
myomata. 

The  crucial  point  in  establishing  the  diagnosis  is  to 
determine  the  relation  of  the  tumor  mass  to  the  body 
of  the  uterus.  This  is  arrived  at  by  an  examination  through  tlie  vagina 
in  order  to  determine  the  position,  size,  and  relations  of  the  cervix  to  the  tumor, 
and  the  relations  of  the  tumor  to  the  pelvic  cavity.  In  some  cases  the  cervix 
projects  into  the  vagina  as  a  rounded  knob,  and  can  be  traced  up  to  a  point 
where  it  enters  directly  into  the  tumor ;  in  others,  the  cervix  is  either  completely 
involved,  and  is  represented  simply  by  a  little  orifice  in  the  tumor,  often  drawn 
high  up  into  the  abdominal  cavity,  or  one  of  its  lips  remains  as  a  ridge  over  this 
orifice,  which  may  be  widened  into  a  slit.  In  cases  which  present  such  charac- 
teristic signs  of  myoma,  the  diagnosis  may  be  made  unhesitatingly  from  the 
vaginal  examination  alone.  Sometimes  the  cervix  can  be  traced  well  above  the 
vaginal  vault,  and  appears  to  be  more  or  less  movable  on  the  surface  of  the  mass 


DIAGNOSIS.  349 

to  whicli  it  seems  to  be  bound  by  adhesions.  In  such  cases  a  rectal  examination 
is  required  to  decide  whether  the  body  felt  above  the  vaginal  vault  and  con- 
tinuous with  the  vaginal  cervix  is  a  small  uterus  on  top  of  a  tumor,  or  whether 
it  is  simply  the  supravaginal  portion  of  the  cervix  and  the  tumor  is  the  enlarged 
body  of  the  uterus. 

In  order  to  make  the  rectal  examination  satisfactory,  the  lower 
bowel  must  be  emptied  by  a  purgative  the  night  before  examination,  and  by  an 
enema  in  the  morning.  The  finger  introduced  into  the  rectum  is  assisted  by 
the  other  hand  pressing  down  through  the  abdominal  walls  to  determine  the  size 
and  position  of  the  supravaginal  cervix.  Particular  attention  is  next  given  to  a 
study  of  the  relation  of  the  cervix  to  the  tumor  by  slowly  and  carefully  carrying 
the  finger  along  the  posterior  surface  of  the  cervix  up  to  the  tumor ;  this  settles 
the  question  whether  the  cervix  enters  into  the  tumor  or  is  simply  attached  to 
its  surface.  It  must  be  borne  in  mind  that  the  distinction  between  cervix  and 
body  is  sometimes  remarkably  emphasized,  the  body  being  occupied  by  the 
growths,  while  the  cervix  remains  unaffected  and  seems  to  be  independent  of 
the  tumor.  When  the  cervix  is  elongated  and  doubt  exists  as  to  whether  it  is 
simply  a  part  or  the  whole  of  the  uterus,  the  introduction  of  a  flexi- 
ble sound  will  settle  the  doubt  by  passing  directly  through  the  cervical  canal 
and  on  into  tlie  body  of  the  growth. 

By  grasping  the  cervix  with  bullet  forceps  and  drawing  it  down  toward  the 
vaginal  outlet,  while  bimanual  palpation  is  made  through  the  rectum  and  the 
abdominal  walls,  the  nature  of  the  connection  between  the  upper  limit  of  the 
cervix  and  the  mass  may  be  still  further  determined.  A  cervix  going  into  the 
mass  will  be  felt  to  make  a  direct  pull  upon  it  at  the  point  of  entrance,  while  if 
the  small  body  above  the  vagina  comprises  the  whole  uterus,  it  will  be  drawn 
down  and  palpated  over  its  fundus  and  shown  to  be  attached  to  the  mass  simply 
by  adhesions. 

Large  myomata,  except  those  which  are  subserous  and  pedunculate,  distort 
and  increase  the  length  of  the  uterine  cavity,  and  this  alteration  often  constitutes 
an  important  factor  in  establishing  the  diagnosis. 

"When  the  fundus  of  the  uterus  can  be  felt  high  up  on  the  tumor,  or  one  of 
the  round  ligaments  is  distinguished  as  a  tense  cord  extending  from  the  main 
body  of  the  mass  down  to  the  inguinal  ring,  or  an  enlarged  ovary  rotated  high 
up  and  to  the  front  can  be  distinctly  palpated,  while  the  vaginal  cervix  is  felt 
below,  the  existence  of  an  elongated  uterine  cavity  is  perfectly  evident.  When 
none  of  these  landmarks  can  be  recognized  with  certainty,  the  length  and  direc- 
tion of  the  cavity  can  be  measured  with  a  flexible  hard  rubber  uterine  sound.  If 
the  sound  does  not  enter  easily  under  the  guidance  of  the  finger,  its  introduction 
may  be  facilitated  by  catching  the  cervix  and  holding  it  with  a  pair  of  bullet 
forceps. 

It  is  essential  during  these  e  x  a  m  i  n  a  t  i  (i  n  s  to  observe  all 
the  individual  peculiarities  of  the  case,  which  may  have  an  im- 
portant bearing  upon  operative  treatment  or  for  future  comparison  to  determine 
whether  any  changes  have  occurred  ;  for  example,  the  size  of  the  tumor  and  the 


350 


MYOMECTOMY — HYSTERO-MYOMECTOMY. 


extent  to  wlncli  it  fills  the  pelvis,  whether  in  one  or  all  directions,  should  be 
noted,  as  well  as  the  condition  and  size  of  the  cervix  and  its  position,  whether  in 


Oiuent.ves. 


CervT 

Fig.  48G. — Pedunculated  Myomata,  giving  a  Perfect  Ballottement.     Anterior  View. 

The  uterus  contains  numerous  interstitial  and  sessile  myomata,  and  on  its  fundus  are  two  pedunculated 
tumors  about  the  size  of  a  child's  head  at  seven  months.  The  abdomen  was  filled  with  ascitic  fluid  just 
sufficient  to  raise  tlie  anterior  wall  2  or  3  centimeters  away  from  the  tumor  on  the  left.  On  giving  the  tumor 
a  slight  blow,  it  disappeared  at  once,  to  return  again  immediately  and  strike  the  finger  a  gentle  blow  back, 
perfectly  imitating  the  ballottement  of  pregnancy.  Note  the  manner  in  which  the  enlarged  omental  vessels 
plunge  directly  into  the  tumor.     %  natural' size. 


the  pelvis  or  drawn  upward  into  the  abdomen.     In  large  tumors  the  abdominal 
enlargement  should  be  recorded  from  the  circular  measurements  of  the  patient's 


PALLIATIVE   TREATMENT.  351 

body,  and  a  good  contour  may  be  made  with  a  flexible  leaden  tape  ;  the  position 
and  size  of  prominent  bosses  are  also  to  be  described.  A  sound  passed  into  the 
bladder  will  show  whether  it  has  suffered  any  displacement  along  with  the 
tumor.  The  degree  of  mobility  of  the  tumor  may  be  tested  by  rocking  it  from 
side  to  side  and  pushing  it  up  from  below. 

One  of  the  most  remarkable  myomata  I  have  ever  seen  exhibited  distinctly 
the  sign  of  ballottement,  hitherto  considered  pathognomonic  of  preg- 
nancy. The  abdomen  was  prominently  distended,  much  in  the  form  of  a  preg- 
nancy of  about  eight  months,  and  the  uterus  was  enlarged  by  two  fibroid  masses 
which  reached  almost  to  the  umbilicus.  There  was  enough  ascitic  fluid  to  fill 
the  flanks  and  occupy  the  space  between  the  tumors  and  the  abdominal  wall.  On 
palpating  the  abdomen  at  a  point  5  or  6  centimeters  above  the  symphysis  noth- 
ing was  felt,  but  on  making  sudden  deep  pressure  through  about  4  centimeters 
of  fluid  a  hard  body  was  encountered  which  instantly  disappeared  from  touch 
and  returned  again  one  or  two  seconds  later,  striking  the  fingers  with  a  decided 
blow  as  it  came  back. 

An  accurate  means  of  recording  changes  in  the  form  of  the  abdomen,  which 
can  be  seen  but  are  difiicult  to  describe,  is  by  photography.  Two  jDictures  should 
be  taken  as  the  patient  lies  on  the  table,  a  side  view  and  a  quartering  one,  on 
4  by  5  plates.  It  is  of  assistance  in  judging  the  size  and  relations  of  the  tumor 
if  the  umbilicus  is  shown  in  the  pictures.  A  picture  taken  from  below  looking 
up  toward  the  chest  shows  the  elevation  of  the  tumor  and  any  asymmetry  be- 
tween right  and  left  sides.  A  photograph  of  the  tumor  after  its  removal  com- 
pletes the  recoi'd. 

Palliative  Treatment. — The  treatment  of  myomata  is  either  expectant,  pallia- 
tive, abortive,  or  radical.  The  great  majority  of  myomatous  uteri  require  no 
treatment  whatever ;  many  of  the  smaller  growths  produce  no  symptoms,  and 
their  discovery  is  often  purely  accidental. 

Frequently  the  patient  herself  is  the  first  to  notice  a  small  abdominal  tumor, 
although  I  have  seen  women  with  a  tumor  as  large  as  a  seven  months'  pregnancy 
who  did  not  know  it  existed.  When  it  is  not  larger  than  a  three  or  four  months' 
pregnancy  and  produces  no  subjective  symptoms  no  treatment  of  any  kind  is 
called  for.  A  careful  examination,  however,  should  be  made  and  the  observa- 
tions recorded,  and  the  patient  advised  to  return  for  examination  at  long  intervals, 
so  that  any  changes  and  the  rate  of  growth  may  be  watched.  No  surgical  treat- 
ment should  be  instituted  when  a  myomatous  uterus  is  complicated  by  an  ad- 
vanced nephritis,  a  double  pyelonephrosis,  or  a  persistent  glycosuria.  I  mention 
each  of  these  complications  because  I  have  met  them. 

Relief  of  Pressure  Symptoms . — Discomfort  in  walking,  backache, 
and  a  sense  of  pressure  will  often  be  relieved  in  a  small  myomatous  uterus, 
where  the  fundus  is  rctroflexed,  by  packing  the  vagina  with  cotton  or  wool 
tam{)ons,  or  by  the  use  of  a  pessary,  which  may  even  be  inserted  without  replac- 
ing the  uterus  and  still  do  good.  When  the  tumor  is  large  enough  to  choke 
the  pelvis  and  does  not  rise  into  the  abdomen,  but  is  held  l)eneath  the  sacral 
promontory,  sometimes  great  relief  follows  its  elevation  into  the  abdomen  under 


352 


MYOMECTOMY — HYSTERO-M  YOMECTOMY. 


an  anesthetic.  Care  must  be  taken  not  to  force  the  displacement  nnless  the  mass 
seems  free  from  adhesions.  There  is  a  decided  risk  in  doing  this,  because  the 
large  vessels  at  the  point  of  attachment  of  the  tumor  to  the  uterus  are  liable  to 
rupture  when  the  pedicle  is  friable. 

Hemorrhage  . — Profuse  menstrual  hemorrhages  with  prolonged  periods, 
lasting  one,  two,  or  three  weeks,  often  accompany  submucous  myomata  and 
large  myomatous  uteri  in  association  with  a  hypertrophy  of  the  uterine  mucosa  ; 
this  may  often  be  relieved  for  a  long  period,  or  even  permanently,  by  dilata- 
tion of  the  cervix  and  a  thorough  curettage  (see  Chapter  XIY). 


Fig.    487. — Large    Globular    Myoma    choking    the    Pelvis;    compues.sinu    Kectum    and    Bladder,   and 
FORCING  the  Bladder  up  into  the  Abdomen. 

iSote  the  retroflexion  of  the  uterus.     About  half  size.     Autopsy,  Jau.  15,  1897. 

There  should  be  no  relaxation  in  the  preparatory  details,  as  described  in 
Chapter  XIV,  as  curettage  may  be  followed  by  a  fatal  termination,  if  great 
care  is  not  observed  in  rendering  the  vagina  and  cervix  as  sterile  as  possible. 
The  posterior  vaginal  wall  is  retracted  with  a  Sims  or  Simon  speculum,  the 
anterior  lip  of  the  cervix  is  caught  by  a  pair  of  bullet  forceps,  and  the  uter- 
ine sound  passed  in  to  determine  the  length,  the  direction,  and  the  size  of  the 


PALLIATIVE   TREATMEXT. 


353 


uterine  cavity.  Guided  bj  this  information,  the  smallest  uterine  dilator  is  in- 
troduced, and  the  cervix  equably  stretched  in  all  directions  as  described.  The 
evidence  of  the  thoroughness  of  the  operation  will  be  shown  by  the    large 


Fig.  488. — The  same  myoma  lifted  up  into  the  abdomen  out  of  its  bed,  showinpr  the  hypertrophy  of  tlie 
anterior  uterine  wall,  and  the  complete  detachment  of  the  bladder  from  the  uterus  and  the  upper  vagina. 
Note  also  the  compression  of  the  rectum. 

amount  of  tissue  discharged  through  the  os  in  the  form  of  pale  shreds  and 
strips  of  mucous  membrane. 

If  the  cervix  is  displaced  upward  it  will  often  be  more  readily  exposed  by 
placing  the  patient  in  the  left  lateral  position.  In  some  of  these  eases,  however, 
the  displacement  is  so  great  and  the  uterine  canal  so  distorted  that  neither  sound 
nor  dilator  can  be  introduced,  and  curettage  is  utterly  impracticable. 


354  MYOMECTOMY — HYSTERO-MYOMECTOM  Y. 

Curettage  performed  under  aseptic  conditions  is  free  from  danger  and 
worthy  of  a  more  general  use,  as  it  often  gives  great  temporary  relief  and  does 
not  prevent  a  subsequent  radical  treatment. 

The  galvanic  electric  current,  used  for  the  same  jjurpose,  is  prob- 
ably the  most  eflicient  means  of  controlling  hemorrhage,  and  producing  such 
permanent  surface  changes  in  the  uterine  nnicosa  as  will  tend  to  prevent  its  re- 
turn. The  current  is  appHed  by  introducing  a  long  positive  platinum  or  carbon 
electrode  high  up  in  the  uterus,  and  placing  a  broad  wet  cotton  or  clay  negative 
electrode  over  the  tumor  on  the  abdominal  wall. 

In  this  way  from  50  to  150  milliamperes  are  used,  the  limit  being  deter- 
mined by  the  sensitiveness  of  the  patient.  The  sittings  last  from  five  to  ten 
minutes,  and  after  each  the  patient  should  remain  an  hour  or  more  in  bed.  The 
application  may  be  repeated  every  five  or  seven  days,  and  usually  in  the  course 
of  two  or  three  months  the  tendency  to  hemorrhage  entirely  disappears. 

Drugs  are,  as  a  rule,  of  little  or  no  service  in  checking  hemorrhage.  In 
rare  instances  an  inhibiting  effect  is  exerted  by  ergotin,  in  the  dose  of  1  to 
2  grains  four  times  daily. 

ABDOMINAL  OPERATIONS  UPON  THE  MYOMATOUS  UTERUS. 

1.  General  indications  for  operation. 

2.  Removal  of  ovaries  and  tubes  without  the  tumor. 

3.  Enucleation  of  the  myomata — myomectomy. 

4.  Removal  of  the  myomatous  uterus,  leaving  the  cervix — hystero-myomec- 
tomy. 

5.  Removal  of  the  myomata  with  the  whole  uterus — pan-hystero- myomec- 
tomy. 

The  indications  for  radical  treatment  by  attacking  the  myomata  directly 
are  absolute  and  relative.  Operation  is  imperative  when  the  tumor 
chokes  the  pelvis  and  is  producing  serious  symptoms  from  pressure  upon  the  rec- 
tum, bladder,  or  ureters,  or  when  the  tumor  occupying  the  abdomen  has  reached 
the  size  of  a  seven  months'  pregnancy  or  larger,  and  continues  to  grow.  Here 
pressure  upon  the  bladder,  ureters,  intestines,  stomach,  and  diajDhragm  usually 
produce  their  characteristic  symptoms,  which  increase  until  they  are  so  distress- 
ing as  to  force  the  removal  of  the  tumor.  The  extirpation  of  the  tumor  is  also 
indicated  when  the  size  is  great  enough  to  interfere  with  the  patient's  occu- 
pation. Exhausting  hemorrhages  also  demand  radical  treatment  if  curettage 
and  electricity  have  failed  to  check  the  flow. 

Relative  indications  are  pain,  more  or  less  persistent,  causing  partial 
or  complete  invalidism  ;  this,  if  not  relieved  by  minor  measures,  may  be  so  dis- 
tressing as  to  necessitate  operation.  The  pain  of  these  cases  is  often  due  to  a 
pelvic  peritonitis  and  the  associated  lesions  of  the  tubes  and  ovaries. 

Troublesome  hemorrhages  and  discomforts  of  all  kinds,  reducing  the  patient 
to  a  semi-invalided  condition,  may  also  be  classed  among  the  relative  indications, 
which  must  be  well  weighed  before  deciding  to  resort  to  an  operation. 


MYOMECTOMY. 


In  some  patients  the  constant  distress  of  mind  from  knowing  that  tliey  have 
a  tumor  forms  a  vahd  indication  for  operation. 

Abdoininal  operations  for  mjomata  are  contra-indicated  when  there  is  grave 
organic  disease  of  other  oi'gans,  which  will  probably  within  a  short  time  prove 
fatal.  Advanced  heart  or  kidney  disease,  phthisis,  emphysema,  and  asthma  all 
contra-indicate  operation. 

In  every  case  the  urine  should  be  examined  with  extreme  care  to  exchide 
nephritis,  pyelonephrosis,  and  diabetes. 

Myomectomy. — Myomectomy  is  the  enucleation  of  a  myoma  or  iil)roid  tu- 
mor without  the  sacrifice  of  any  material  portion  of  the  uterus ;  it  is  thus  con- 
trasted with  hystero- myomectomy,  which  is  the  removal  of  the  uterine  body 
together  with  the  tumor,  and  with  pan-hystero-myomectomy,  which  is  the  re- 
moval of  tlie  entire  uterus  -^-ith  its  myomata.  The  defect  created  by  the  re- 
moval of  the  tumor  is  closed  in  by  interrupted  sutures  uniting  the  base  and  the 
edges  of  the  wound,  and  leaving  a  noi'nial  uterus  functionally  perfect.  Ab- 
dominal myomectomy  is  one  of  the  most  actively  conservative  of  all  operative 
procedures,  and  is  the  counterpart  of  the  vaginal  extirpation  of  submucous 
myomata.     (See  Chapter  XYIII.) 

Myomectomy  is  especially  adapted  to  the  ti-eatment  of  single  or  of  isolated 
tumors,  so  disposed  that  they  can  be  readily  excised  or  shelled  out  of  their 
beds  without  undue  injury  to  or  loss  of  the  uterine  tissue.  It  should  therefore 
be  elected  as  the  proper  mode  of  treatment  of  all  isolated  pedunculate,  and  of 
many  isolated  sessile,  interstitial,  or  broad-ligament  growths.  I  have  treated  in 
this  way  a  uterus  containing  as  many  as  nine  myomata,  each  one  of  which  was 
removed  by  a  separate  incision,  as  well  as  another  containing  twelve  myomata. 
No  more  important  advance  can  be  made  by  the  gynecologist  in  the  immediate 
future  than  by  extending  the  indications  for  myomectomy  and  narrowing  the 
field  of  hystero-rayomectomy,  and  so  saving  the  uterus  wherever  possible. 

Myomectomy  should  always  be  preferred  to  hystero- 
m y  o  m e c t o m y  i  n  a  y  o u  n g  wo m a n  ,  pro^^ded  there  are  no  complicat- 
ing conditions,  such  as  an  extreme  anemia,  in  which  case  the  prime  indications 
are  to  check  the  hemorrhages  and  to  avoid  a  protracted  operation. 

Another  contraindication  to  myomectomy  is  the  presence  of  any  extensive 
pelvic  inflammatory  disease,  particularly^  of  pelvic  abscesses,  or  the  presence 
of  ovarian  or  dermoid  cysts. 

Myomectomy  also  should  not  be  performed  when  there  exists  any  grave  dis- 
ease of  other  abdominal  organs  or  of  the  thoracic  viscera. 

Wlien  the  uterus  is  larger  than  a  six  months'  pregnancy  the  dilficulties  of 
closing  the  wounds  made  by  the  removal  of  the  large  tumors  is  so  great  that  for 
the  present  the  indications  for  myomectomy  have  not  been  extended  beyond 
this  limit. 

With  these  few  plain  limitations,  myomectomy,  within 
the  proper  age  limit,  must  always  be  the  operation  of 
election,  and  if  hystero-myomectomy  is  performed,  definite  reasons  nmst  be 
given  why  the  radical  instead  of  the  conservative  plan  of  treatment  is  selected. 


356 


MYOMECTOMY — HYSTERO-MYOMECTOMY'. 


Myomatous  tumors  may  be  enucleated  from  the  size  of  a  pea  up  to  that  of 
an  adult  head  or  larger,  in  any  number,  and  wherever  and  however  situated  or 
attached. 

Categorically  stated,  cases  suitable  for  abdominal  myomectomy  are,  in  general, 
all  single  and  discrete  tumors  which  can  be  clearly  isolated,  and  in  particular — 

(a)  All  pedunculate  myomata, 
where  the  removal  of  the  tumor 
will  leave  a  normal  uterus. 

(b)  All,  even  the  largest,  subse- 
rous or  interstitial  myomata  which 
are  well  defined  in  relation  to  the 
body  of  the  uterus,  whether  single 
or  multiple. 

(c)  Multiple  small  myomata  in 
any  number. 

(d)  Broad-ligament  myomata. 

(e)  A  myoma  localized  at  one 
cornu  of  the  uterus. 

(f)  Submucous  myoma  too  large 
to  be  taken  out  by  the  vagina. 

In  careful  hands,  with  the  best 
technique  possible,  myomectomy  is 
a  safe  operation,  but  an  inexperi- 
enced, indifferent  operator,  and  one 
whose  technique  is  slipshod,  will  in- 
evitably lose  many  cases  from  hem- 
orrhage and  from  sepsis.  Under 
such  circumstances  the  conservative 
myomectomy  is  a  far  more  danger- 
ous operation  than  the  more  radical 
hy  stero -my  omectomy. 

Much  can  be  done  before  the 
operation  to  determine  whether  a  mycmectomy  or  a  hystero-my omectomy  should 
be  performed,  by  making  a  thorough  examination.  Where,  for  example,  the 
rectal,  vaginal,  and  abdominal  examinations  show  that  the  tumor  springs  from 
the  uterus  by  a  well-defined  pedicle,  and  that  there  are  no  other  tumors  in  the 
uterus,  the  surgeon  will  be  able  to  assure  the  patient  beforehand  that  at  the 
operation  he  will  merely  remove  the  tumor,  and  that  there  will  be  no  mutila- 
tion. Also,  when  a  careful  bimanual  examination  has  shown  that  the  uterus  is 
occupied  by  several  well-defined  tumors  from  the  size  of  a  walnut  to  that  of  a 
hen's  egg,  the  operator  may  then  anticipate  that  a  myomectomy  will  be  possible, 
and  the  same  may  he  said  regarding  any  number  of  small  myomata. 

The  expectation  tliat  a  myomectomy  will  be  performed  may  also  be  cher- 
ished whenever  a  single  myoma  is  found  either  laterally,  or  before  or  behind 
the  uterus,  and  the  uterine  canal  is  shown  by  measurement  not  to  be  much 


Fig.  489. — Uterus  after  Extirpation  of  the  Myoma- 
tous Tumor. 

Showing  great  muscular  hypertrophy,  measuring, 
when  returned  to  the  abdomen,  14  x  17  centimeters.  A 
row  of  twenty-nine  sutures  used  in  closing  the  incision 
in  the  uterine  wall.     Jan.  9,  1897.     %  natural  size. 


MYOMECTOMY. 


lengthened  out,  for  such  an  examination  demonstrates  the  fact  that  the  tumor 
springs  more  from  the  upper  part  of  the  body,  where  enucleation  is  always  easier. 
Whenever  a  mass  of  myomata,  however  large,  springs  from  the  fundus,  and 
the  examination  shows  that  the  uterine  canal  is  not  at  all,  or  not  much  length- 
ened, and  the  ovaries  are  low  down  on  the  pelvis  beside  the  body  of  the  utenis, 
the  operator  may  then  also  expect  to  remove  the  mass  alone  from  the  fundus  by 
a  myomectomy. 

With  increasing  experience  in  performing  myomectomies,  after  eliminating 
the  possibility  of  any  grave  extra-pelvic  comphcations,  and  assurmg  himself 
that  there  is  no  extensive  pelvic  inflammation,  the  skillful  operator  will  be  able 
to  assure  all  young  patients  with  myomatous  uteri  which  do  not  rise  above  the 
umbilicus  that  he  will  in  all  human  probability  be  able  to  extirpate  the  tumors 
and  leave  the  uterus,  ovaries,  and  oviducts. 

The  election  of  an  abdominal  instead  of  a  vaginal  myomectomy  for  a  large 
submucous  tumor  is  made  after  determining  its  size  and  relations  by  a 
vaginal  examination,  and  then  estimating  the  difficulties  and  dangers  of  the  vagi- 
nal route  as  greater  than  the  abdominal,  on  account  of  a  contracted  cervix  and 
a  vaginal  outlet,  often  quite  narrow,  making  it  exceedingly  awkward  to  get  at 
the  entire  mass  and  bring  it  away  piecemeal. 

Operation  . — The  general  principles  governing  the  operation  are : 

(a)  A  good  exposure  of  the  tumors  and  the  uterus  through  a  free  abdominal 
incision  with  an  elevated  pelvis. 

(b)  The  isolation  of  the  tumor  (brought  outside  if  possible  i  by  surrounding 
it  with  gauze. 

(c)  The  incision  around  the  pedicle  or  through  the  capsule,  exposing  the 
tumor. 

(d)  The  temporary  control  of  hemorrhage  by  clamps  and  comjjression  of 
the  main  vascular  trunks,  as,  for  example,  by  placing  a  ligature  around  the  cer- 
vical portion  of  the  uterus. 

(e)  The  enucleation  of  the  tumor  from  its  bed. 

(f)  The  permanent  control  of  hemorrhage  by  ligatures  and  buried  sutures, 
and  sometimes  by  ligating  the  uterine  arteries. 

(g)  The  closure  of  the  uterine  incisions,  giving  careful  attention  to  the 
angles,  and  seeino-  that  no  hemorrhao:e  continues  between  the  sutures. 

(h)  Closure  of  the  abdominal  incision  without  a  drain. 

The  great  danger  after  the  operation  is  hemorrhage  which  can  only  be  pre- 
vented by  a  most  careful  attention  to  the  steps  detailed.  It  is  an  important  rule 
always  to  inspect  the  wounds  fur  hemorrhage,  with  the  table  dropped  level,  be- 
fore closing  the  abdomen. 

Pedunculate  Myomata. — The  abdominal  incision  must  be  made 
large  enough  to  get  the  tumor  out  by  its  smallest  axis,  togetjier  with  the 
fundus  of  the  uterus ;  the  intestines  are  then  protected  by  gauze  and  an  assistant 
grasps  and  compresses  the  uterus  tightly  just  below  the  pedicle  to  control  the 
hemorrhage,  while  the  operator  rapidly  makes  an  incision  around  the  tumor  up 
on  its  pedicle  from  2  to  3  centimeters  from  the  uteruie  attachment,  closer  to  the 


358 


MYOMECTOMY — H  YSTEKO-M  YOMECTOM  Y. 


uterus  at  the  ends,  and  the  mass  is  removed.     Actively  bleeding  vessels  are  at 
once  caught  by  artery  forceps.     The  freest  oozing  will  usually  be  found  at  the 


Fig.  4'.>0. — Myomatous  Uteru.s,  Conservative  Opekation. 
Kemoving  three  large  myoiiiata  (J/,  M^  M)  without  sacrificing  the  uterus.     May  11,  1S96. 

peripherj^  or  in  the  center  of  the  stump,  and,  owing  to  the  nature  of  the  tissue, 
it  is  not  possible  to  pick  up  bleeding  points  and  throw  a  ligature  about  them  in 


Fig.  491. — Conservative  Treatment  of  the  Myomatous  Uterus. 

Showins  the  method  of  grasping  the  large  posterior  tumor  and  niakintf  traction  wliile  an  oval  incision  is 
made  not  far  from  its  base  through  the  enveloping  uterine  wail  down  to  the  tumor,  which  is  shelled  out  of 
its  base  by  tractioia  and  dissection. 


MYOMECTOMY. 


359 


the  ordinary  way.     The  best  plan  is  to  control  actively  bleeding  areas  down  the 
middle  of  the  pedicle  by  passing  a  mattress  suture  around  each  one,  including 
the  adjacent  tissues,  and  tying  it  tight.     Large  vessels  at  the  periphery  are  best 
controlled  by  passing  a  liga- 
ture under  the  vessel  in  the 
uterine   tissue  a  short  dis- 
tance from  the  edge  of  the 
incision. 

The  opposite  sides  of  the 
incision  are  next  firmly  ap- 
proximated by  a  series  of 
interrupted  deep  catgut  su- 
tures. The  sutures  must  be 
laid  so  as  to  make  the  most 
pressure  on  the  bleeding 
points  and  thus  aid  in  con 
trolling  the  hemorrhage. 
Every  particle  of  bleeding 
must  be  checked  before 
closing  the  abdomen. 

Subserous    Sessile 
and  Interstitial  My- 
oma t  a  . — Sessile  and  inter- 
stitial tumors  vary  in  size  from  masses  as  large  as  a  uterus  five  months  preg- 
nant down  to  pealike  nodules    on    the    surface  or  buried  in  the  uterine  wall. 
The  larger  tumors  when  interstitial  lie  encapsulated  in  a  mass  of  hypertrophied 
uterine  tissue. 

The  operation  for  their  removal  consists  in  a  linear  incision  through  the 
capsule  of  peritoneum  or  uterine  tissue,  down  into  the  white  fibrous  tissue  of  the 
tumor,  grasping  the  exposed  tumor  with  a  pair  of  stout  claw  forceps,  and  elevat- 
ing it,  as  it  is  gradually  shelled  out  of  its  bed  by  the  fingers,  or  preferably  by 
some  flat  blunt  instrument,  like  the  handle  of  a  scalpel  or  closed  scissors. 


Fig.  492. — Same  uterus  after  removal  of  the  tumors,  showinjij 
the  broad  bases  of  uterine  tissue  now  about  to  be  brought  together 
by  buried  and  interrupted  catgut  sutures,  drawing  the  lips  of  the 
w'ounds  as  indicated  bv  the  crossed  arrows. 


Fui.  493.— Cillen's  Myoma  Enlcleatou. 


If  the  uterine  cavity  is  opened  it  must  at  once  be  wiped 
clean  and  dry  and  care  taken  not  to  spread  its  contents  over  the  wound.  In- 
terrupted catgut  ligatures,  should  be  used  in  closing  the  cavity.  In  passing 
the  deep  sutures  they  should  reach  down  to  the  mucosa,  but  should  not  pene- 
trate it. 

In  one  case  I  tore  up  the  entire  uterine  nuicosa  of  the  anterior  wall  from 
cervix  to  fundus,  in  the  form  of  a  triangular  flap ;  this  was  closed  with  a  delicate 


360  MYOMECTOMY — HYSTERO-MYOMECTOM  Y. 

eontmuous  catgut  suture  and  the  rest  of  the  uterine  wound,  made  by  the  extir- 
pation of  a  large  tumor,  was  closed  in  by  buried  and  interrupted  sutures.  Per- 
fect recovery  followed. 

In  another  case  I  found  it  necessary  to  resect  at  least  a  third  of  the  uterine 
cavity. 

It  may  be  necessary,  if  the  tumors  are  large,  to  control  temporarily  the 
uterine  circulation  by  an  elastic  ligature  or  a  gauze  rope  twisted  around  the  body 
of  the  uterus  below  the  tumor.  AVhen  the  cervical  portion  of  the  uterus  can  be 
grasped  the  assistant  is  able  to  control  the  circulation  for  a  wdiile  by  squeezing  it 
with  two  hands. 

The  sutures  should  be  laid  with  a  large  curved  needle  armed  with  a  carrier, 
which  is  boldly  carried  deep  down  through  the  uterine  tissue  from  one  side  of 
the  incision  across  to  the  other.  Numerous  sutures  and  tight  ligation  will  con- 
trol the  bleeding  in  all  cases.  The  cavity  produced  by  the  enucleation  of  the 
tumor  must  always  be  closed  perfectly  from  bottom  to  toj),  to  avoid  leaving  a 
dead  space  with  the  formation  of  a  blood  clot  which  is  liable  to  become  septic. 
Interrupted  buried  sutures  in  one,  two,  or  three  tiers  will  serve  to  approximate 
the  wound  below  the  surface.  Wherever  there  is  bleeding  a  suture  is  passed 
and  tied  tight.  After  the  wound  is  well  brought  together  in  this  way  the  elastic 
ligature  or  the  gauze  rope  is  cut  to  restore  the  circulation,  and  additional  deep 
sutures  are  passed  wherever  there  is  any  bleeding.  At  least  one  tight  suture 
should  be  placed  at  each  angle  of  the  wound,  and,  if  necessary,  beyond  the 
angle,  as  that  is  the  point  most  liable  to  continue  bleeding  after  the  abdomen  is 
closed. 

The  utmost  pains  must  be  taken  not  to  handle  the  structures  which  are  to 
be  left  behind  any  more  than  is  absolutely  possible. 

The  hands  of  the  assistants  should  be  protected  by  sterilized  rubber,  thread, 
or  silk  gloves.  The  uterus  should  be  laid  open  and  surrounded  with  gauze.  As 
soon  as  the  overlying  tissue  is  incised  and  the  tumor  exposed  and  caught  with 
forceps,  the  lips  of  the  incision  should  be  grasped  with  gauze  pads  and  worked 
back  off  from  the  tumor  as  it  is  being  drawn  forw^ard.  When  the  tumor  is 
removed  it  will  lessen  the  risks  of  sepsis  if  the  operator  will  tie  all  the  ligatures 
and  sutures  with  lingers  protected  by  rubber  finger  stalls. 

It  will  be  possible  in  this  way  to  conduct  an  extensive  myomectomy  from 
beginning  to  end  without  once  coming  into  direct  contact  with  the  structures 
which  are  to  be  returned  to  the  abdominal  cavity. 

An  interesting  "example  of  what  may  be  done  by  myomectomy  to  conserve 
the  uterus  is  afforded  by  the  case  of  M.  A.  (No.  1576),  operated  upon  Nov.  5, 
1892.  An  incision  10  centimeters  long  M^as  made  through  the  abdominal  walls, 
and  eight  subserous  and  interstitial  myomata  were  removed  from  the  uterus  by 
seven  separate  incisions.  The  duration  of  the  operation  down  to  the  closure 
of  the  abdominal  incision  was  thirty  minutes. 

The  following  case  shows  further  what  may  be  done  in  the  way  of  conserva- 
tism :  F.  E.  S.,  4055,  operated  upon  Jan.  6,  1896,  had  a  myomatous  uterus 
filling  the  pelvis  and  rising  well  above  the  brim,  about  as  large  as  a  four  and  a 


MYOMECTOMY. 


361 


half  months'  pregnancy.  Per  vaginatib  the  cervix  seemed  to  be  attached 
directly  at  the  central  portion  of  the  mass,  and  the  fundus  could  not  be  felt. 
The  abdomen  was  opened,  and  the  tumor,  which  just  filled  out  the  pelvis, 
brought  up  and  out  of  the  incision.     The  fundus,  with  tubes  and  ovaries,  lay 


Fig.  494. — Myomatous  Uterus  from  which  Eight  Myomata  were  enucleated  by  Seven  Incisions. 

May  11,  1S96. 

in  front  of  the  tumor,  which  was  developed  in  the  lower  posterior  portion  of 
the  uterus.  I  split  the  capsule  1  to  2  centimeters  thick,  and  rapidly  enucleated 
a  fibroid  mass  12  x  10  x  10  centimeters  in  size,  without  exj^osing  the  uterine 
cavity  at  all.  The  bleeding  was  free  but  not  excessive,  and  was  controlled  by  eight 
to  ten  pairs  of  forceps. 
Several  vessels  were  tied 
with  catgut,  and  the  en- 
tire bed  of  the  tumor 
obliterated  by  continu- 
ous catgut  sutures. 

The  edges  of  the 
wound  were  united  by 
interrupted  catgut  su- 
tures, and  extended, 
when  closed,  15  centi- 
meters from  a  point  be- 
neath the  left  utero-ova- 
rian  ligament  downward 
in  the  middle  line  to  the 

pelvic  floor.     A  small  myoma,  1*5  by  1*5  centimeter,  was  also  taken  out  in 
front  of  the  left  cornu.     (See  also  Figs,  -lO-i  and  495.) 

C  o  r  n  u  a  1  Myoma . — When  a  myoma  is  situated  deep  in  the  uterine  tissue 
at  one  of  the  cornua,  lifting  up  the  uterine  tube,  the  uterus  may  be  saved  by 


Fig. 


495.— Uterus   from  which   Eight  Myomata  were  removed   by 
Seven  Incisions. 


Showing  incisions  closed  by  interrupted  catgut  suture.-; 


362 


MYOMECTOMY — IIY'STERO-M  YOMECTOM  Y. 


removing  tlie  tumor  witli  the  tiil^e,  and,  if  need  be,  tlie  ovarj  of  that  side.  The 
circulation  of  tlie  uterus  is  controlled  either  by  an  elastic  ligature  around  the 
cervical  end,  or,  l)etter,  by  tying  the  uterine  artery  of  that  side  well  below  the 
cornu  and  ligating  the  ovarian  vessels  out  near  tlie  brim  of  the  pelvis.  A  small 
oval  incision  is  then  made,  to  include  the  uterine  end  of  the  tube,  exposing  the 
tumor  in  its  bed  ;  the  growth  is  then  enucleated,  as  in  a  case  (S.  L.,  2500)  oper- 
ated on  Jan.  15,  1894,  where  the  tube  and  ovary  of  the  side  where  the  tumor 
lay  were  involved  in  peritoneal    adhesions.     The  uterine  cavity  M'as  opened. 


Fio.  496. — Large  Submucou.s  Myoma. 

Adapted  to  removal  by  abdominal  section  by  splitting  open  the  uterus  and  enucleating  the  tutnor,  and 
then  sewing  up  the  uterine  incision.     %  natural  size. 


The  wedge-shaped  flaps  left  after  tlie  enucleation  were  brought  firmly  and 
neatly  together  and  the  wliole  dro])ped,  and  the  abdomen  closed  without  a 
drain. 

Extirpation  of  Submucous  Myomata  per  Abdomen . — We 
owe  to  Prof.  A.  Martin,  of  Berlin,  the  extension  of  the  field  of  abdominal 
myomectomy  to  the  removal  of  sulmiucous  myomata.  (See  Cent.f.  Gyn.,  July 
31,  1886.) 


MYOMECTOMY.  3G3 

Tliis  operation  is  indicated  when  the  myoma  is  the  size  of  a  child's  head 
or  larger,  and  the  entire  cervical  canal  is  undilated,  or  when  a  part  of  a  large 
myoma  has  been  extruded  through  the  cervix,  leaving  a  large  intra- uteiine  mass 
which  can  not  be  reached  readily  through  the  vagina. 

Whenever  the  tumor  can  be  reached  by  the  vagina  it  should  be  removed  by 
morcellation. 

Before  the  operation  it  is  necessary  to  disinfect  the  vagina  and  the  uterine 
cavity  by  irrigation  with  a  five-per-cent  solution  of  creolin,  and  then  to  pack 
the  uterus,  if  it  can  be  reached,  with  iodoform  or  sterilized  gauze,  to  prevent 
the  escape  of  secretions  over  the  wound  surface  and  into  the  peritoneal  cavity 
when  the  uterus  is  opened  from  above.  If  there  is  a  foul  uterine  discharge,  it 
will  be  wiser  to  delay  operation  until  by  douches  and  drainage  its  character  is 
changed  ;  if  an  immediate  operation  is  imperative,  it  will  be  safest  to  sew  the 
cervix  up  tight  and  remove  the  entire  uterus  when  the  abdomen  is  opened. 

The  operation  consists  in  the  following  steps  : 

1.  Opening  the  abdomen. 

2.  Lifting  out  the  uterus  onto  a  gauze  napkin,  and  packing  gauze  into  the 
posterior  pelvis  all  around  the  uterus. 

3.  A  temporary  rubber  ligature  around  the  cervical  portion  of  the  uterus  to 
control  hemorrhage. 

4.  Opening  the  uterine  cavity  and  shelling  out  the  tumor. 

5.  Closing  the  uterus  by  suture  and  returning  it  to  the  abdominal  cavity. 

6.  Closiner  the  abdominal  incision. 

An  incision  in  the  linea  alba  is  made  large  enough  to  bring  the 
uterus  out  onto  the  abdomen.  A  thick  gauze  pad  is  placed  beneath  it,  and  tow- 
els or  gauze  are  packed  close  around  its  lower  portion  and  down  into  the  inci- 
sion, to  prevent  any  possible  contamination  in  case  any  of  its  contents  should 
escape  when  it  is  opened. 

A  provisional  rubber  or  gauze  ligature  is  thrown  about  the  uterus  below  the 
tumor  and  tied  before  the  uterine  incision  is  made.  The  position  of  the  pedicle 
ma^  sometimes  be  discovered  by  sHding  the  uterine  walls  over  the  tumor  inside 
of  it ;  the  pedicle  will  be  found  at  the  fixed  point  which  refuses  to  slide. 

The  incision  should  be  made  by  preference  on  the  anterior  wall,  or  it  may 
be  made  across  the  fundus,  away  from  the  pedicle,  in  the  long  axis  of  the  uterus, 
just  below  the  fundus,  and  it  should  extend  down  to  the  cervix.  A  few  strokes 
of  the  knife  lays  the  uterus  open  from  top  to  bottom,  exposing  the  tumor. 

The  gauze  in  the  uterus  is  then  taken  out  with  forceps,  and  a  piece  of  fresh 
sterilized  gauze  packed  in  to  protect  the  margins  of  the  incision,  while  the  tumor 
is  grasped  with  a  sterilized  towel  or  a  piece  of  gauze  and  peeled  from  its  base 
by  torsion  or  removed  by  incising  its  capsule  and  peeling  it  out.  The  utmost 
care  must  be  constantly  exercised  not  to  let  the  tumor  or  any  of  the  contents  of 
the  uterine  cavity  touch  the  edges  of  the  incision. 

In  a  suppurating  myoma  such  a  procedure  is  rarely  if  ever  justifiable. 

The  uterine  incision  is  closed  by  catgut  sutures  about  1  centimeter  apart, 
entering  and  emerging  about  half  a  centimeter  from  the  margins  of  the  inci- 


364  MYOMECTOMY — H  YSTERO-M  YOMECTOMY'. 

sion,  and  carried  down  to  the  mucosa,  but  not  entering  it.  The  sutures  should 
be  tied  as  rapidly  as  possible  until  all  active  bleeding  is  checked.  After  the 
deep  sutures  are  tied,  any  remaining  areas  of  imperfect  approximation  may  be 
corrected  by  half-deep  sutures  of  catgut,  passing  5  to  8  millimeters  into  the  tis- 
sue, as  in  the  Cesarean  operation.  I  prefer  to  use  chromicized  catgut  at  those 
points  which  include  large  vessels. 

Infective  material  having  been  carefully  excluded,  the  abdominal  cavity  re- 
quires no  cleansing.  The  gauze  j^ads  supporting  the  uterus  are  removed  and 
the  uterus  replaced  in  the  pelvic  cavity  in  anteflexion,  so  as  to  keep  the  intes- 
tines from  coming  in  contact  with  the  line  of  incision.  The  abdominal  cavity  is 
then  closed,  and  the  after-treatment  conducted  as  usual. 

Hystero-myomectomy, — Hystero-myomectomy  is  the  correct  name  of  the  oper- 
ation commonly  described  at  length  as  "  supravaginal  hysterectomy  for  fibroid 
tumors."  It  consists  in  the  removal  of  a  part  or  the  whole  body  of  the  uterus 
with  its  tumor  masses,  usually  amputated  through  the  cervix. 

The  history  of  the  evolution  of  our  present  methods  of  treating  fibroid 
tumors  of  the  uterus  is  deeply  interesting,  particularly  to  an  American,  on  ac- 
count of  the  important  part  played  by  our  own  surgeons  in  developing  the 
methods  which  are  now  recognized  as  the  best. 

This  subject  has  commanded  the  careful  attention  of  Dr.  E.  W.  Cushing,  of 
Boston  {Ann.  of  Gyn.  and  Pediatry.,  1895,  p.  573),  and  more  recently  of  Dr. 
C.  P.  Noble,  of  Philadelphia,  to  whose  painstaking  studies  I  am  particularly 
indebted  for  the  historical  information  which  follows. 

In  April,  1845,  Dr.  W.  L.  Atlee  published  a  paper  in  the  Amer.  Jour,  of  the 
Med.  Sci.  entitled  Case  of  Successful  Extirpation  of  a  Fibrous  Tumor  of  tJie 
Peritoneal  Surface  of  the  Uterus  hy  the  Large  Peritoneal  Section.  The  opera- 
tion was  performed  in  Aug.,  1844.  From  this  time  on  Atlee  continued  to 
operate  upon  fibroid  tumors,  and  he  contributed  to  the  literature  of  the  subject 
throughout  his  long  professional  career.  He  generally  operated  for  the  removal 
of  the  tumor  only,  either  by  the  vagina  or  by  abdominal  section  ;  but  he  occasion- 
ally did  hysterectomy.  One  of  his  most  important  papers  was  a  prize  essay 
published  in  the  Trans,  of  the  Amer.  Med.  Assoc,  1853,  p.  547,  and  entitled 
The  Surgical  Treatment  of  Certain  Fibrous  Tumors  of  the  Uterus,  heretofore 
considered  heyond  the  Resources  of  Art. 

Dr.  Walter  Burnham,  of  Lowell,  Mass.,  operated  upon  a  patient  June  26, 
1853,  with  the  expectation  of  removing  an  ovarian  cyst,  but  the  tumor  proved 
to  be  a  fibroid  which  was  extruded  from  the  wound  by  the  act  of  vomiting  and 
could  not  be  replaced.  Burnham  therefore  had  to  remove  it ;  he  did  this  by 
first  taking  away  two  pedunculated  fibroids  to  reduce  the  size,  and  then  passing 
"  a  strong  double  ligature  through  the  neck  of  the  uterus,  which  was  tied  on 
each  side  ;  then  to  make  doubly  sure  against  hemorrhage,  a  ligature  was  placed 
around  the  whole  neck."  After  this  the  broad  ligaments  and  cervix  were 
divided  and  no  bleeding  followed.  The  ovaries,  which  were  diseased,  were  also 
removed.  The  cervix  was  dropped,  and  the  ligatures,  brought  out  at  the  lower 
angle  of  the  wound,  after  the  fashion  of  the  day,  came  away  during  the  fifth 


HYSTERO-MYOMECTOMY.  365 

week,  and  the  patient  recovered.  This  was  the  first  recovery  after  hysterectomy 
for  fibroid  tumor.  Burnham  performed  altogether  fifteen  hysterectomies  with 
tliree  recoveries ;  the  second  and  third  operations  were  done  in  1854  and  1857 
(see  Dr.  J.  C.  Irish,  Hyderectomy  for  the  Treatment  of  Fibroid  Tumors,  Trans, 
of  the  Amer.  Med.  Assoc,  1878,  p.  447). 

Dr.  G.  Kimball,  of  Lowell,  was  the  first  to  perform  a  deliberate  hysterectomy 
for  fibroid  tumors  of  the  uterus,  having  previously  made  a  correct  diagnosis. 
He  operated  Sept.  1,  1853,  upon  a  patient  in  a  bad  condition  from  protracted 
uterine  hemorrhages.  At  the  operation  the  cervix  was  transfixed,  each  lialf 
ligated,  and  the  uterus  amputated  in  tlie  supravaginal  portion  ;  the  cervix  was 
dropped  and  the  ligatures  brought  out  at  the  lower  angle  of  the  wound.  The 
woman  was  well  eight  months  later,  but  the  ligatures  were  still  attached  (see 
G.  Kimball,  Successful  Case  of  Extirpatwn  of  the  Uterus,  Boston  Med.  and 
Surg.  Jour.,  May,  1855).  According  to  Bigelow,  in  1883,  Kimball  had  per- 
formed eleven  hysterectomies  with  six  recoveries  and  five  deaths. 

Dr.  Marcy  was  one  of  the  fii-st  to  devote  particular  attention  to  the  method 
of  treating  the  cervix,  and  described  an  improved  way  of  dealing  with  the  pedi- 
cle by  sewing  it  across  with  the  cobbler's  stitch  {Trans,  of  the  Amer.  Med. 
Assoc,  1882,  p.  203j. 

Dr.  T.  A.  Emmet  in  1884  {Principles  and  Practice  of  Gynecology,  p.  612) 
utilized  the  peritoneum  anterior  to  the  uterus  to  cover  the  cervical  stump  in  a 
hysterectomy  done  for  a  dermoid  cyst  of  the  ovary  and  a  fibro-cystic  uterus. 
In  discussing  the  principles  of  the  operation  the  imj)ortant  advance  thus  made 
in  the  retroperitoneal  treatment  of  the  stump  is  clearly  pointed  out. 

Dr.  M.  A.  D.  Jones,  Feb.  16,  1888,  performed  tlie  fii-st  American  pan- 
hysterectomy for  uterine  fibroid  {New  YorJt  Med.  Jour.,  Aug.  25  and  Sept.  1, 
1888),  originating  this  form  of  operation  independently  of  Bardenheuer,  whose 
work  was  not  known  at  that  time  in  America. 

Dr.  J.  Eastman  has  indelibly  associated  his  name  with  the  operation  of 
pan-hysterectomy  by  his  pioneer  work,  and  by  the  invention  of  new  instniments 
facilitating  the  operation.  His  first  operation  was  performed  Sept.  21,  1889 
{Lidiana  Med.  Jour.,  1890,  also  Med.  Fortnightly,  Jan.  15,  1896). 

One  of  the  most  revolutionary  changes  was  that  devised  by  Dr.  L.  A.  Stim- 
son,  of  New  York,  who  proposed  and  practiced  the  systematic  ligation  of  the 
ovarian  and  uterine  arteries  in  their  course  as  a  proper  preliminary  to  hysterec- 
tomy {New  York  Med.  Jour.,  March  9,  1889,  and  Med.  Neios,  July  27,  1889). 
By  this  simple  improvement  in  the  technique  the  dangerous  mass  ligatures 
applied  to  the  broad  ligaments  were  done  away  with  and  the  risks  of  sepsis  and 
hemorrhage  greatly  reduced.  Dr.  J.  R.  Goffe  {Amer.  Jour.  Ohs.,  April,  1890, 
vol.  xxiii,  p.  372)  originated  and  carried  out  a  well-defined  enucleation  followed 
by  the  complete  covering  of  the  cervical  stump  with  peritoneal  flaps,  which  he 
called  "  an  intra-abdominal  but  extraperitoneal  method  of  dis])osing  of  the  ped- 
icle." The  first  operation  was  done  May  29,  1888,  and  repeated  three  times, 
and  then  presented  before  the  Obstetric  Section  of  the  Academy  of  Medicine  in 
March,  1890. 


366  MYOMECTOMY — HYSTERO-MYOMECTOMY. 

While  in  this  wav  citing  and  giving  credit  to  American  work,  I  would  not 
slight  the  admirable  work  done  in  France  and  Germany  by  such  well-known 
men  as  Velpeau,  Amussat,  Bardenheuer,  Schroder,  Martin,  Zweifel,  Chrobak, 
Sanger,  Fritsch,  and  latest  of  all,  Olshausen  (see  Veit's  Handhuch,  1897).  In 
England  the  names  of  Keith,  Thornton,  Bantock,  Milton,  of  Cairo,  and  Hey- 
wood  Smith  are  indelibly  associated  with  hysterectomy. 

The  indications  for  h  y  s  t  e  r  o  -  m  y  o  m  e  c  t  o  m  y  are,  in  gen- 
eral— 

(a)  Discomfort  or  ill  health  produced  by  the  tumor,  interfering  with  occupa- 
tion or  comfortable  getting  about. 

(b)  All  myomata  filling  the  lower  abdomen  from  the  size  of  a  six  or  seven 
months'  pregnancy  upward. 

(c)  Smaller  tumors  choking  the  pelvis  and  pressing  injuriously  on  the  rectum 
or  bladder. 

(d)  Rapid  growth  of  the  tumor. 

(e)  Repeated  hemorrhages,  which  are  exhausting  to  the  patient  and  can  not 
be  controlled  by  simpler  means. 

(f)  Persistent  intense  dysmenorrhea,  seriously  affecting  the  general  health,  an 
indication  to  be  accepted  only  with  great  caution. 

(g)  Severe  pain,  often  associated  with  attacks  of  peritonitis,  and  usually 
due  to  pelvic  peritonitis,  tubal  and  ov^arian  inflammatory  disease,  and  pelvic 
abscess. 

(h)  Myomata  complicated  by  cancer  of  the  uterus,  ovarian  cysts,  dermoid 
cysts,  ovarian  fibroids, 

I  feel  it  my  duty  to  utter  an  urgent  warning  against  accept- 
ing the  simple  fact  of  the  presence  of  a  tumor  as  a  suffi- 
cient indication  for  operation.  The  conscientious  operator  should 
always  be  able  to  show  either  that  the  continued  presence  of  the  tumor  in  some 
way  is  a  menace  to  life,  or  that  its  presence  is  incompatible  with  a  comfortable 
existence. 

I  have,  however,  operated  two  or  three  times  solely  on  account  of  the  dis- 
tressed mental  condition  of  the  patient,  induced  by  the  knowl- 
edge that  there  was  a  tumor  which  she  could  feel  in  the  abdomen.  Until  the 
operation  was  done  it  was  impossible  to  allay  the  fears  or  to  persuade  the  patient 
to  think  of  anything  else  but  the  tumor,  and  no  reasoning  had  any  effect. 

The  one  indication  most  generally  accepted  is  the  large  size  of  the  tumor 
which  fills  the  lower  abdomen.  Here,  on  making  the  incision  and  exposing  the 
growth,  we  find  the  small  intestines  forced  up  under  the  diaphragm  and  out  into 
the  flanks,  accounting  for  the  interference  with  circulation,  respii*ation,  and 
digestion ;  frequently,  too,  the  ureters  are  so  pressed  upon  as  to  cause  hydro- 
ureter  and  hydronephrosis,  and  a  careful  examination  of  the  urine  before  ojDcra- 
tion  may  reveal  albuminuria,  with  hyaline  and  granular  casts.  A  pyelonephrosis 
may  readily  supervene  upon  the  hydronephrosis.  Hyaline  degeneration  of  the 
heart  muscle  and  arterio-sclerosis  arc  sometimes  seen  in  old  cases  and  appear  to 
be  caused  by  the  stasis  in  the  circulation  due  to  pressure.     When  the  pressure 


HYSTERO-MYOMECTOMY.  367 

is  relieved  the  kidneys  often  recover,  judging  by  the  fact  that  the  albuminuria 
soon  disappears. 

Persistent  discomfort  and  protracted  severe  pains  at  the  menstrual  period 
only  become  valid  indications  for  an  operation  when  general  treatment,  such  as 
mild  sedatives  and  hygienic  measures,  rest,  massage,  etc.,  have  been  faithfully 
tried,  and  sufficient  time  has  elapsed  to  demonstrate  the  fact  that  spontaneous 
relief  can  not  be  expected. 

Hemorrhages  in  smaller  tumors  may  often  be  controlled  by  curettage  or  by 
galvanism ;  but  in  the  largest  tumors  the  vaginal  cervix  is  often  so  small  and 
displaced  so  high  into  the  abdomen  that  an  intra-uterine  application  of  the  elec- 
trode is  dangerous  or  impossible. 

A  firm  vaginal  pack  will  also  often  check  hemorrhage  at  once,  and  by  this 
means  the  patient's  strength  may  be  husbanded  from  month  to  month. 

When  a  soft  myoma  has  been  discovered  and  every  subsequent  examination 
at  intervals  of  a  few  months  shows  that  it  is  growing  rapidly  and  has  reached  the 
size  of  a  four  or  five  months'  pregnancy,  the  operator  has  valid  ground  for  its 
removal. 

I  would  call  especial  attention  to  the  fact  that  those  myomata  which  are  con- 
stantly associated  with  great  pain  almost  invariably  belong  to  the  class  of  com- 
plicated cases  in  which  a  tubal  and  ovarian  inflammatory  disease  will  also  be 
found.     Even  pyosalpinx  is  not  an  uncommon  addition. 

The  best  time  to  operate  is  when  the  patient  has  been  put  in  the 
best  possible  condition  her  disease  will  admit  of.  Women  who  are  enfeebled 
and  worn  out  should  be  put  to  bed  and  built  up  for  a  time.  When  the  monthly 
period  produces  great  disturbances,  the  best  time  to  operate  is  just  before  an  ex- 
pected period.  I  have  even  operated  in  several  instances  without  disadvantage 
a  day  or  two  after  the  period  had  begun. 

In  operating  upon  anemic  patients  unusual  precautions  must  be  taken  against 
further  loss  of  blood,  to  the  extent  of  clamping  all  the  small  bleeding  vessels  in 
the  abdominal  walls  and  controlling  at  once  all  oozing  from  the  cellular  tissues 
in  the  pelvis  during  the  operation.  The  loss  of  a  few  ounces  of  blood,  ordi- 
narily insignificant,  suffices  in  these  cases  to  add  to  the  shock  easily  induced  in 
the  patient's  weakened  condition. 

Wherever  a  free  hemorrhage  has  occurred  in  the  course  of  a  hystero-myo- 
mectomy,  enough  to  give  rise  to  any  marked  degree  of  depression,  there  should 
be  no  hesitation  in  infusing  under  the  breasts  a  half  liter  or  a  liter  of  normal 
salt  solution  (see  Chapter  XXII,  p.  70). 

The  loss  of  bodily  heat  must  be  avoided  in  every  way  by  keeping  the  intes- 
tines within  the  body  if  possible,  or  by  covering  with  hot  gauze  any  coils  that 
may  be  exposed  to  the  air.  The  body  and  limbs  should  be  wrapped  in  blankets 
and  a  hot-water  bag  placed  at  the  feet. 

If  the  pulse  begins  to  run  up  during  the  operation  it  is  best  to  give  hypo- 
dermics of  strychnin,  one  fortieth  of  a  grain,  repeated  in  doses  of  one  sixtieth  of  a 
grain  at  intervals  of  half  an  hour.  A  stimulant  rectal  enema  of  brandy  (spiritus 
vini  gallici,  5  ij  »  ammoniae  carbonas,  gr,  xx  ;  and  hot  salt  solution,  q.  s.  ad  f  3  vj) 


36S  MYOMECTOMY — HYSTERO-MYOMECTOMY. 

should  be  given,  -sritli  tlie  pelvis  well  elevated,  before  the  patient  is  lifted  from 
the  operating  table. 

The  duration  of  the  entire  operation  varies  from  twenty  to 
thirty  minutes  in  easy  cases,  and  from  sixty  to  eighty  minutes  in  the  difficult. 
Operations  extending  over  an  hour  are  apt  to  produce  a  decided  depression. 
The  duration  down  to  the  complete  enucleation  of  the  uterus  with  the  tumors 
lasts  from  three  in  the  easiest  to  fifteen  or  twenty  minutes  in  the  most  difficult 
cases ;  the  rest  of  the  time  is  taken  up  in  the  details  of  the  treatment  of  the 
wound  made  by  the  excision,  covering  it  in  with  the  peritoneum  and  closing  the 
abdominal  incision. 

The  principal  causes  of  the  high  rate  of  mortahty  following  hysterectomy  as 
done  by  our  immediate  predecessors  were  hemorrhage  and  sepsis.  These  dangers 
may  now  be  avoided  by  following  the  improved  technique  recently  elaborated. 

The  technique  of  hystero-myomectomy  includes  : 

(a)  Preliminary  preparation  of  the  field,  including  the  skin  and  the  vagina. 

(b)  Opening  the  abdomen. 

(c)  DeHvering  the  tumor  if  possible. 

(d)  Ligation  of  the  ovarian  vessels  and  the  round  ligament  of  one  side,  usu- 
ally the  left,  and  opening  the  top  of  the  broad  ligament. 

(e)  Detachment  of  the  vesico-uterine  fold  of  peritoneum  from  side  to  side, 
and  pushing  it  well  down  so  as  to  separate  the  bladder  from  the  cervix. 

(f)  Ligation  of  the  uterine  vessels  of  the  same  side. 

(g)  The  amputation  of  the  uterus  in  the  cervical  portion,  leaving  a  cup- 
shaped  pedicle, 

(h)  Clamping  the  uterine  artery  of  the  opposite  side,  clamping  the  round 
ligament,  and  clamping  the  uterus  with  the  ovarian  vessels,  followed  by  removal 
of  the  tumors. 

(i)  Applications  of  ligatures  in  place  of  the  forceps. 

(j)  Suturing  the  cervical  stump. 

(k)  Covering  the  wound  area  with  peritoneum. 

(1)  Cleansing  the  peritoneal  cavity, 

(m)  Closure  of  the  abdominal  incision  without  a  drain. 

Hystero-myomectomy  without  Complications. — P  r  e  1  i  m  i  n  a  r  y  Prepara- 
tion.— If  the  patient  is  in  a  reduced  condition  the  operation  should  be  post- 
poned until  a  maximum  improvement  has  been  secured.  The  preparations  im- 
mediately preceding  the  operation  have  been  fully  detailed  in  Chapter  XX,  p. 
9.     Especial  care  must  be  taken  to  disinfect  the  vagina  thoroughly. 

Opening  the  Abdomen . — The  patient  is  placed  on  the  table  with  her 
pelvis  elevated,  and  an  incision  from  6  to  20  centimeters  (24  to  8  inches)  long  is 
made  over  the  most  prominent  part  of  the  tumor,  taking  care  to  cut  slowly  and 
deliberately,  so  as  not  to  incise  the  tumor  on  opening  the  peritoneum.  I  have 
seen  a  large  vein  cut  in  this  way  bleed  profusely  and  cause  the  loss  of  much 
valuable  time  in  checking  the  unnecessary  hemorrhage.  It  is  best  to  open  the 
peritoneum  first  in  the  ujiper  part  of  the  incision,  so  as  to  avoid  the  risk  of  cut- 
ting the  bladder,  which  is  often  raised  several  inches  out  of  the  pelvis.     The 


HYSTERO-MYOMECTOMY    WITHOUT   COMPLICATIOXS. 


369 


exact  position  of  the  fundus  of  the  bladder  should  be  determined  beforehand 
with  a  sound.  The  hand  is  then  introduced  within  the  abdomen  and  passed 
over  the  tumor  on  all  sides,  making  an  examination  which  gives  an  experienced 
operator  in  a  few  seconds  an  accurate  idea  as  to  the  character  of  the  operation, 
and  enables  him  to  estimate  the  mobility  and  relations  of  the  uterus  with  its  tu- 
mors, the  presence  or  absence  of  adhesions,  and  particularly  the  relations  of  the 
pedicle  to  the  pelvis,  whether  broad  or  narrow,  and  whether  there  is  anv  upward 
displacement  of  the  sigmoid  flexure  or  the  bladder.  If  the  tumor  is  now  found 
to  be  too  large  to  be  delivered,  the  incision  is  lengthened  by  raising  its  upper 
angle  on  two  fingers  and  protecting  the  peritoneum  with  a  sponge  while  cut- 
ting boldly  upward  with  a  knife.  Stout  angled  scissors  may  be  used  for  the 
same  purpose  when  the  abdominal  walls  are  thin. 

Delivering  the  Tumor . — Tumors  limited  to  the  body  of  the  uterus 
can  be  readily  lifted  out  of  the  abdominal  cavity  at  once,  and  for  this  reason 
they  constitute  a  more  favorable 
class  for  operation,  as  a  natural  pedi- 
cle is  offered  by  the  unaffected  cer- 
vical part  below  the  mass. 

As  soon  as  the  tumor  escapes,  a 
warm  gauze  pad  should  be  shj)ped 
in  under  the  incision  covering  the 
intestines. 

In  some  large  multilocular  fibro- 
cysts  a  succession  of  deliveries  of 
single  tumors  is  necessary  before 
the  entire  mass  lies  without  the 
abdomen.  Sometimes  after  a  group 
of  large  tumors  have  been  lifted 
out  in  this  way  the  pelvis  will  still  be  found  choked  by  a  tumor  which  is  onlv 
dislodged  after  a  prolonged  effort.  If  moderate  direct  traction  on  such  a  mass 
fails,  an  assistant  should  introduce  two  fingers  into  the  vagina  and  make  strong 
upward  pressure  in  the  axis  of  the  superior  strait,  setting  it  free. 

Care  must  be  taken  not  to  make  such  traction  on  a  pedunculate  tumor  as  will 
result  in  tearing  its  pedicle  and  causing  a  hemorrhage  which  might  prove 
troublesome.  A  large  tumor,  the  size  of  a  child's  head,  may  sometimes  be  deliv- 
ered with  advantage  with  obstetrical  forceps. 

Ligation  of  the  Ovarian  Yessels  and  Round  Ligament 
of  One  Side . — A  fine  silk  ligature  (No.  2)  may  be  used  to  ligate  the  ovarian 
vessels,  however  large.  The  outer  pelvic  extremity  of  the  l)road  ligament,  often 
swollen  by  a  congeries  of  large  purple  veins  which  cross  the  pelvic  brim  under 
the  caput  coli  on  the  right  side  and  under  the  sigmoid  flexure  on  the  left,  is 
now  gathered  up  between  the  thumb  and  forefinger,  and  the  clear  space  below  the 
vessels  sought  for,  through  which  a  ligature  is  passed  and  tied  tightly  controlling 
the  vessels.  It  is  always  surprising  to  see  a  bunch  of  vessels  as  large  as  three  or 
four  fingers  contract  down  to  a  mere  strand  in  the  bite  of  a  ligature.     A  second 


Fig.  497. — Schematic  Diaor.\m. 
Showing  the  line  of  incision,  beginning  with  the  left 
ovarian  vessels  and  ending  with  the  right,  in  the  extirpa- 
tion of  the  myomatous  uterus. 


370  MYOMECTOMY — HYSTEKO-MYOMECTOMY. 

ligature  or  a  clamp  is  applied  4  or  5  centimeters  away,  toward  the  uterus,  and 
the  vessels  cut  between  the  two,  at  a  good  distance  from  the  first  Hgature. 

In  a  woman  under  forty  years  of  age  it  is  better  to  leave  both  ovaries  in  the 
pelvis,  with  or  without  the  uterine  tubes ;  by  doing  this,  although  menstruation 
ceases,  the  disagreeable  symptoms  of  the  artificially  induced  menopause  are 
avoided.  In  this  case  the  first  and  the  last  ligatures  are  applied  near  the  horn 
of  the  uterus. 

The  round  ligament,  often  enlarged  and  vascular,  is  now  lifted  up 
near  the  uterus  and  tied  with  catgut  and  cut  through,  and  the  uterine  end 
clamped. 

The  top  of  the  broad  ligament  is  opened  up  by  these  incisions. 

Detaching:  the  Vesico-uterine  Peritoneum  . — The  uterus  is 
now  drawn  back  and  the  anterior  loose  peritoneal  fold  along  the  curved  line  of 
the  utero-vesical  reflection  is  cut  through  from  round  ligament  to  round  liga- 
ment. As  the  bladder  is  raised,  the  loose  cellular  tissue  beneath  it  is  exposed, 
and  it  may  be  still  further  freed  by  a  rapid  dissection  with  knife  or  scissors.  In 
ordinary  cases  there  is  no  bleeding  of  any  moment.  The  uterus  is  now  pulled 
well  up,  while  the  operator  completes  the  separation  of  the  bladder  by  taking  a 
sponge,  firmly  compressed  and  held  in  a  sponge  forceps,  and  pushing  the  bladder 
down  with  it  on  all  sides,  baring  the  cervical  end  of  the  uterus  ahnost  or  quite 
down  to  the  vaginal  junction.  This  also  brings  into  view  the  uterine  arteries 
and  veins  on  the  same  side  of  the  uterus.  Sometimes,  when  these  vessels  are 
not  exposed  quite  clearly  enough,  they  may  be  brought  into  better  view  by 
drawing  the  uterus  forward  and  nicking  the  sharp  posterior  peritoneal  margin 
behind  the  cervix. 

Ligation  of  the  Uterine  Vessels. — The  large  uterine  veins  on 
the  side  of  the  uterus  are  recognized  by  their  dark  color,  and  the  smaller  cord- 
like artery  can  be  plainly  felt  pulsating.  These  vessels  are  now  securely  ligated 
close  to  the  side  of  the  cervix  by  a  silk  ligature,  introduced  on  a  large  curved 
needle,  passed  close  to  the  cervical  tissue  but  not  entering  it.  The  uterus  is  now 
drawn  over  toward  the  other  side,  and  the  operator  takes  a  spud  and  begins  the 
amputation  by  cutting  through  the  uterine  vessels  from  6  to  10  millimeters  above 
the  ligature.  The  assistant  stands  with  open  artery  forceps  in  hand  ready  to 
grasp  any  bleeding  vessel  by  chance  left  out  of  the  hgature.  The  cut  vessels 
above  on  the  tumor  side  are  better  clamped  or  tied  in  mass  to  keep  the  blood 
from  constantly  oozing  out  and  obscuring  the  field  of  the  operation. 

The  uterus  is  now  completely  divided  in  its  cervical  portion,  at  a  point  just 
above  the  vaginal  junction,  by  cutting  deliberately  through  the  tissue  with  a 
spud  or  knife,  with  successive  strokes.  The  cervical  canal  is  usually  found 
about  the  middle  and  is  recognized  by  the  presence  of  a  little  glairy  mucus.  As 
soon  as  this  canal  is  cut  across,  a  pad  of  gauze  several  folds  thick  is  laid  beneath 
the  upper  cut  surface  to  keep  any  intra-uterine  secretions  from  escaping  onto 
the  wound,  and  the  canal  below  is  wiped  out.  The  cutting  is  now  continued 
across  toward  the  opposite  side  more  slowly,  as  the  little  remaining  bridge  of 
tissue  shows  the  severance  is  nearly  completed.     The  bleeding  from  the  cut  sur- 


HYSTERO-MYOMECTOMY    WITHOUT    COMFLICATIOXS. 


171 


face  is  usually  so  slight  tliat  it  may  be  neglected,  or  at  most  one  or  two  forceps 
only  need  be  applied.  It  is  a  good  plan  when  the  cervix  is  nearly  divided  to 
cut  upward  for  1  or  2  centimeters  so  as  to  leave  behind  a  thin  shell  of  cervical 
tissue  and  expose  the  opposite  utei-ine  vessels  at  a  higher  level,  where  it  is  much 
easier  to  tie  them  ^^^thout  risk  of  including  the  ureter. 

Clamping  the  Opposite  Uterine  Vessels . — When  the  last 
strands  of  uterine  tissue  are  severed  or  l)reak,  as  the  uterus  is  drawn  up  and 
out  and  rolls  over  more  onto  its  side,  the  opposite  uterine  veins  and  artery 
come  into  view.     The  beginner  \vill  expect  to  find  these  vessels  hugging  the 


Ov.ves. 


TlouncL  lig". 


Fiii.  4',"b. — The  Opekation  of  IIvsteko-mvomectomy. 
By  a  continuous  incision  froui  left  to  ri^lit,  litratinjr  or  clamping  at  the  points  indicated  by  t)ie  arrows; 
first,  the  left  ovarian  vessels  ( Ov.  ves.  i ;  next,  tlie  round  ligament,  and  then  the  left  uterine  artery  ( l^t.  Art.). 
Finally  the  cervix  is  cut  across,  and  the  uterus  pulled  awaV  until  the  right  uterine  vessels  are  exposed. 

uterus  tightly,,  and  will  be  surprised   to  note  the  considerable  cellular  interval 
which  often  separates  them  as  they  arc  exposed  in  this  way. 

It  is  best  not  to  clamp  them  as  soon  as  seen,  but  to  pull  the  uterus  up  fur- 
ther until  the  separation  between  the  cut  surfaces  amounts  to  several  centime- 
ters. At  this  higher  level  the  artery,  at  first  not  so  plainly  seen,  comes  clearly 
into  view  and  may  be  clamped  by  itself,  the  uterus  rolled  still  more  over  on  its 
side,  and  the  round  ligament  clamped  close  to  it  and  divided,  and  finally,  vrith  a 
little  more  traction,  the  ovarian  vessels  are  seen  and  clamped  and  cut,  and  the 
whole  mass  is  finally  freed  and  taken  away. 


372 


MYOMECTOMY — HY'STERO-MY'OM  ECTOM  Y. 


The  uterine  veins  often  do  not  bleed  when  severed  in  this  way  ;  if  they  do, 
it  is  easy  to  control  them  with  one  or  two  pairs  of  forceps. 

Ligating  the  Vessels  controlled  by  Forceps . — As  soon  as 
the  uterus,  with  the  tumor,  is  lifted  away  the  operator  looks  over  the  whole 
field  to  see  that  there  is  no  active  hemorrhage  going  on. 


Fig.  499. — The  Last  Step  in  the  Enucleation  of  the  Myomatous  Uterus. 
The  mass  is  rolled  out  of  the  abdomen  and  is  now  attached  only  by  the  round  ligament,  ovary,  and  tube. 

He  then  proceeds  to  tie  the  vessels  on  the  side  controlled  by  forceps,  taking 
up  first  the  round  ligament  which  is  encircled  with  a  catgut  ligature  ;  next  the 
ovarian  vessels  are  controlled  by  transfixing  the  clear  space  and  tying  them  with 
a  fine  silk  ligature.  The  uterine  artery  is  now  drawn  up  and  tied  at  a  point 
w^ell  above  the  cupped  stump.     This  avoids  any  risk  of  tying  the  ureter. 

By  grasping  the  cervical  stump  with  a  pair  of  tenaculum  forceps  it  can  be 
pulled  up  into  the  abdominal  incision  within  easier  reach,  bringing  with  it  the 
uterine  vessels,  which  are  then  also  under  better  control. 

Two  ligatures  should  be  placed  upon  every  important  vessel,  the  first  tied  in 
the  course  of  the  enucleation  and  the  second  when  the  enucleation  is  completed. 

Suturing  the  Stump. — The  next  step  is  to  close  the  stump,  but  be- 
fore doing  this  the  operator  must  look  minutely  and  patiently  over  the  whole 
field  and  pick  up  any  minute  bleeding  points  with  forceps  and  tie  them  with 
fine  catgut.  The  stump  is  now  closed  over  the  cervical  canal  by  passing  from 
three  to  five  or  more  catgut  sutures  in  an  antero-posterior  direction  and  tying 
each  one  as  it  is  passed.     If  the  stump  is  inclined  to  ooze  at  places,  this  may  be 


COMPLICATIONS    OF   HYSTERO-MYOMECTOMY.  373 

checked  by  making  one  of  the  sutures  include  that  point  and  tying  it  tight.  In 
passing  these  sutures  the  mucous  membrane  of  the  canal  must  not  be  included. 
By  this  suturing  the  cup-shaped  pedicle  is  changed  into  a  transverse  linear 
wound.  I  do  not  disinfect  the  cervical  canal  any  more,  unless  there  is  such  evi- 
dence of  infection  as  a  discharge  of  pus  from  the  uterus  or  a  muco-purulent 
plug  in  the  canal.  In  this  case  the  canal  should  be  wiped  out  with  gauze  as 
soon  as  cut  across,  and  afterward  dissected  out  with  a  narrow  sharp  knife  and 
forceps. 

Covering  in  the  Whole  Wound  Area  with  Vesical  Peri- 
toneum.— The  large  loose  flap  of  peritoneum  which  lies  in  front  of  the 
pedicle  and  the  broad  ligaments  is  now  picked  up  with  long  rat-tooth  forceps 
and  drawn  over  the  stump  and  attached  to  the  posterior  peritoneum  from  side 
to  side  by  a  continuous  intermediate  catgut  suture ;  the  round  ligaments  and 
the  pedicles  of  the  ovarian  vessels  are  turned  in  between  the  layers  of  peri- 
toneum, and  all  that  is  left  of  the  large  wound  is  a  fine  line  of  approximation 
across  the  middle  of  the  pelvis,  practically  converting  the  pelvis  into  the  male 
form  by  the  removal  of  the  organs  between  the  rectum  and  the  bladder.  This 
is  done  by  starting  the  suture  at  the  stump  of  the  ovarian  vessels  at  the  brim  of 
the  pelvis,  and  continuing  it  down  across  the  pelvis  and  up  to  the  opposite  ova- 
rian vessels,  as  described  in  Chapter  XXVIII. 

If  there  is  a  large  space  left  in  the  cellular  tissue  it  will  be  best  to  unite  the 
peritoneum  with  interrupted  or  mattress  sutures,  so  that  any  blood  which  escapes 
from  capillaries  will  mm  into  the  peritoneum  and  be  absorbed  instead  of  forming 
a  hematocele. 

Cleansing  the  Peritoneum . — If  the  jjeritoneum  has  been  much 
soiled  by  blood  in  the  course  of  the  operation,  one  or  two  liters  of  normal  salt 
solution  (0'6  of  one  per  cent)  at  a  temperature  of  4:3*3  C.  (110  F.)  should  be 
poured  into  the  pelvis  and  abdominal  cavity,  and  rapidly  sponged  out  until  all 
foreign  material  has  been  removed. 

Closing  the  Incision . — The  small  intestines  are  drawn  into  the 
lower  part  of  the  abdomen,  and  the  omentum  is  sought  out  and  spread  between 
them  and  the  anterior  wall. 

The  abdomen  is  finally  completely  closed,  without  drainage,  and  dressed  as 
described  in  Chapter  XX,  the  salt  solution  enema  given,  and  the  patient  put 
to  bed. 

Mortality. — ^In  one  hundred  consecutive  abdominal  hysterectomies,  m- 
cluding  all  kinds  of  complications,  I  have  lost  two  cases. 

Complications  of  Hystero-myomectomy. — The  operation  of  hystero-myomectomy 
varies  all  the  way  from  the  simplest  to  one  of  the  most  complicated  diflScult  pro- 
cedures in  gynecology.  Cases  like  those  just  described  as  the  type  are  for  the 
most  part  easy  of  operation,  and  as  a  rule  make  a  prom^it  undisturbed  recovery. 
A  long  list  of  complications  is,  however,  added  when  we  analyze  one  hundred 
consecutive  cases,  and  CTnimerate  all  the  difiiculties  encountered.  Some  of  these 
complications  add  but  slightly,  others  more,  and  still  others  enormously,  to  the 
diflBculty  of  enucleation  ;  and  when  several  or  more  complications  of  various 


374  MYOMECTOMY — HYSTERO-MYOMECTOM  Y. 

sorts  exist  in  the  same  case,  the  difficulties  are  eiilianced  to  an  even  greater  degree. 
This  matter  has  grown  to  one  of  sucli  great  importance  that  I  deem  it  necessary 
to  speak  in  detail  of  each  of  these  complicating  conditions,  first  giving  a  cate- 
gorical list  of  all  those  which  are  most  important. 
They  are  in  general  of  four  classes  : 

1.  Complications  due  to  adhesions  to  and  affections  of  the  surrounding  struc- 
tures. 

2.  Complications  brought  about  by  changes  in  the  tumors  themselves. 

3.  Complications  due  to  the  positions  of  the  myomatous  masses. 

4.  Complications  due  to  pregnancy,  ascites,  and  other  causes  in  particular. 
Complications    due    to  Adhesions    and    Affections  of    the 

Surrounding  Structures. — (a)  Inflammatory:  1.  Simple  adhesions  of 
tubes  and  ovaries.  2.  Hydrosalpinx.  3.  Pyosalpinx  and  abscess  of  the  ovary. 
4.  Encysted  peritonitis.  5.  Omental  adhesions.  6.  Parietal  adhesions.  7.  Ad- 
hesions to  rectum,  sigmoid,  colon,  and  small  intestines.  8.  Adhesions  to  vermi- 
form appendix.     9.  Adhesions  to  liver  and  suspensory  ligament. 

(b)  Tumors  of  the  ovary  :  10.  Ovarian  cystoma.  11.  Dermoid  cyst.  12. 
Fibroid  ovary.  13.  Ovarian  hydrocele.  14.  Ovarian  hematoma.  15.  Carci- 
noma of  the  ovary. 

(c)  Diseases  of  cervix  and  uterine  mucosa :  16.  Cancer  of  the  cervix.  17. 
Cancer  of  the  uterus  associated  with  myoma.  18.  Tuberculosis  of  the  endome- 
trium. 

Complications  due  to  Changes  in  the  Tumors  Them- 
selves.— 19.  Cysto-myoma.  2i>.  Telangiectatic  myoma.  21.  Cystic  myoma 
with  twisted  pedicle.  22.  Suppurating  myoma.  23.  Adeno-myoma  uteri  dif- 
fusum  benignum. 

Go mplications  due  to  the  Location  of  the  Tumors . — 
24.  Elevation  of  tubes  and  ovaries  high  out  of  the  pelvis.  25.  Globular  myoma 
filling  pelvis.  26.  Myomata  wedged  in  pelvis.  27.  Myoma  below  the  vesical 
peritoneum.  28.  Myoma  below  posterior  pelvic  peritoneum.  29.  Myoma  in 
upper  part  of  broad  ligament.  30.  Myoma  in  broad  ligament  proper.  31. 
Myoma  developed  antero-laterally,  twisting  uterus.  32.  Myoma  developed 
postero-laterally.  33.  Myomata  developing  under  the  pelvic  peritoneum  in 
several  of  these  positions  at  once.     34.  Myomata  displacing  the  ureters  upward. 

Complications  due  to  Pregnancy,  Ascites,  and  Other 
Causes . — 35.  Myoma  with  pregnancy.  36.  Myoma  simulating  pregnancy, 
37.  Myoma  and  ascites,  feeble  heart,  nephritis,  pyelone])hrosis,  etc. 

Several  other  conditions  may  be  enumerated,  too,  which  add  to  the  gravity, 
but,  except  the  last,  are  beyond  the  possibility  of  direct  treatment  at  the  time  of 
operation ;  such  are  the  cases  Math  extreme  anemia,  rapid  feeble  heart,  valvular 
lieart  disease,  nephritis,  and  pyelonephrosis. 

1,  2,  3.  Adherent  Tubes  and  Ovaries;  Hydrosalpinx;  Pyo- 
salpinx.— The  complications  due  to  inflammatory  lesions 
and  adhesions  in  the  surrounding  structures  must  in  general  be  dealt  with 
like  similar  adhesions  under  other  circumstances,  as  described  in  Chapter  XX 


COMPLICATIONS    OF    HYSTERO-MYOMECTOMY.  375 

on  General  Principles.  It  is  only  necessary  to  speak  here  first  of  tlie  frequency 
with  which  myomata  are  complicated  by  pelvic  peritonitis,  and,  second,  of  the 
difficulties  of  releasincr  inflamed  ovaries  and  tubes,  from  the  fact  that  they  are 
often  so  completely  buried  behind  the  tumors,  or  wedged  down  into  the  pelvis, 
that  they  are  hard  to  reach  without  injuring  some  of  the  great  vascular  sinuses 
in  their  immediate  neighborhood.  When  they  can  be  got  at  without  special 
difficulty,  an  adherent  tube  and  ovary,  or  a  hydrosalpinx,  or  even  a  pyosalpinx, 
may  be  gently  released  by  gradually  working  the  fingers  down  between  the  in- 
flamed structures  and  the  posterior  pelvic  wall  until  their  under  surface  is 
reached,  when  they  are  carefully  freed  from  their  adhesions  to  the  pelvic  floor 
and  walls,  and  as  they  are  brought  up  and  out  of  the  pelvis,  detached  also  from 
their  broad-ligament  adhesions. 


Fig.  500. — Complicated  IIystero-myomectomy. 
Myomatous  uterus  with  liydrosalpinx  on  the  risrlit  side,  and  a  large  ovarian  cyst  on  the  left  side.     Ilystero- 
myon'iectomy.     Recovery,     i'ath.  No.  245.    ^  natural  size. 

It  frequently  happens  on  the  left  side  that  these  inflamed  structures  are  cov- 
ered in  by  an  adherent  sigmoid  flexure,  and  in  order  to  reach  them  this  must  be 
dissected  off  by  pulling  it  away  from  the  tumor,  so  as  to  expose  the  cellular 
interval  which  is  cut  Avith  scissors.  When  the  inflamed  tube  and 
ovary  are  hard  to  reach,  either  because  they  are  sheltered 
by  the  tumor  or  because  they  are  wedged  down  in  the 
pelvis,  or  when  the  adhesions  are  so  dense  that  it  is  dan- 
gerous to  break  them  up  by  touch  without  the  controlling 
aid  of  sight,  it  is  best  to  begin  the  enucleation  by  seeking 
out  the  ovarian  vessels  at  the  outer  extremity  of  the  broad 
ligament  and  tying  them  at  two  ])oints  and  cutting  them  between,  and 
then  tying  off  the  round  ligament  in  the  same  way.  By  this  means  the  top  of 
the  broad  ligament  is  opened  up  and  the  uterus  so  far  freed  that  it  can  be 
lifted  up  and  out  enough  to  allow  free  access  to  the  inflamed  structures,  which 
can  now  often  be  better  attacked  from  the  exposed  front  of  the  broad  ligament. 

Where  pus  is  present  unusual  care  must  be  taken  to  diminish  the  risks  of 
infection  by  aspirating  and  taking  away  as  much  of  it  as  possible,  and  then  pro- 
tecting the  infected  structures  by  abundant  gauze  until  they  are  removed.  The 
risk  of  an  infection  is  greater  here  than  in  almost  any  other  abdominal  opera- 
tion on  account  of  the  wide  area  of  cellular  tissue  bared  between  the  broad  liga- 
ments by  the  enucleation  of  the  uterus  and  tumors. 
•16 


376 


MYOMECTOMY — HYSTERO-MYOMECTOMY. 


Adhesions,  hydrosalpinx,  and  pelvic  abscesses  in  the 
right  side  are  best  dealt  with  toward  the  end  of  the  enu- 
cleation; as  the  uterus  is  rolled  up  and  out  of  the  pelvis  after  clamping  the 
right  uterine  artery,  the  right  adnexa  can  be  easily  reached  and  freed  from  adhe- 
sions under  inspection  by  attacking  them  from  the  front. 

One  of  the  most  complicated  cases  is  shown  in  Fig.  501. 

The  patient  had  a  large  umbilical  hernia,  containing  a  portion  of  the  omen- 
tum, which  adhered  to  the  edges  of  the  ring;   the  omentum  was  also  closely 


BrnaU 
Dntest.- 


Fig.  501. — Complicated  Hystero-myomectomy. 

The  abdomen  i»  filled  with  a  large  myomatous  uterus  with  intestinal  and  omental  adhesions.  There  is. 
an  umbilical  hernia,  and  on  the  right  side  of  the  pelvis  a  large  abscess  opening  into  tlie  small  intestine.  In 
front  of  the  abscess  lies  the  uterine  tube  full  of  pus.    Enucleation.    Kecovery.    K.  L.     Operation,  March  24,. 


adherent  to  the  whole  front  of  the  large  myomatous  uterus,  which  extended 
from  the  pelvic  floor  well  above  the  umbilicus.  The  adherent  bladder  was 
drawn  high  up  out  of  the  pelvis,  and  over  it  lay  a  large  thickened  nterine 
tube  distended  with   pus,  while   on  the   right  side  there  was  a  suppurating 


COMPLICATIONS    OF    HYSTERO-M YOMECTOMY.  377 

ovarian  cyst  communicating  by  a  fistulous  opening  witli  a  loop  of  the  small 
intestine.  The  proper  plan  of  jDrocedure  in  such  a  ease  is  to  work  with  great 
deliberation  until  the  adhesions  are  separated  sufficiently  to  allow  the  myoma- 
tous uterus  to  be  handled  and  to  expose  the  left  broad  ligament.  Gauze 
should  be  packed  around  on  all  sides  to  protect  the  peritoneum  and  the  in- 
testines from  contamination,  and  any  accessible  sacs  of  pus  should  be  tapped 
so  that  they  will  collapse,  affording  more  room  and  obviating  the  risks  of 
rupture  and  extensive  contamination.  After  the  enucleation  the  hernia  and 
the  intestinal  fistula  are  treated.  If  the  fistula  is  well  closed  a  drain  is  not 
necessary, 

4.  Encysted  P  er  i  t  o  n  i  t  i  s  . — In  two  cases  I  have  encountered  an  exten- 
sive encysted  peritonitis  filling  the  posterior  pelvis  ;  in  one  instance  this  was  not 
discovered  until  the  adhesions  at  the  brim  of  the  pelvis  were  broken  through  and 
the  clear  serous  fluid  gushed  out  of  a  pocket  lined  by  peritoneum  and  extending 
as  far  down  as  the  floor  of  the  pelvis.  In  the  other  case  the  fluctuation  was  so 
clearly  felt  per  vaginam  that  the  diagnosis  between  an  ovarian  cystoma  and  a 
fibroid  uterus  remained  doubtful,  until  the  abdomen  was  opened  and  the  myo- 
matous masses  were  exposed,  when  the  fluctuation  was  found  to  be  due  to  the 
sac  of  fluid  pent  up  behind  the  uterus. 

5.  Omental  Adhesions . — The  omentum  often  adheres  to  the  larger 
fibroid  uteri,  and  in  many  instances  its  entire  free  border  is  attached  like  a 
corona  to  the  anterior  and  upper  convex  surface  of  the  tumor.  The  omental 
vessels  in  these  cases  may  be  greatly  enlarged,  standing  out  like  whipcords  or 
looking  like  great  bunches  of  earthworms.  These  vessels,  instead  of  ramifying 
on  the  surface  of  the  tumor,  seem  to  plunge  vertically  into  the  substance,  and  I 
have  shown  by  injection  that  while  they  do  contribute  some  small  vessels  to  the 
capsule,  for  the  most  part  they  communicate  directly  with  the  deeper  portions 
of  the  mass. 

Sometimes  all  the  tissue  between  the  omental  vessels  disappears,  and  they 
stand  out  hke  so  many  separate  whipcords  from  6  to  10  or  12  centimeters  long. 

Ordinarily  this  complication  is  easily  met  by  tying  off  the  whole  omentum 
■svith  eight  or  ten  fine  silk  ligatures,  taking  care  not  to  bunch  too  many  large 
vessels  in  one  ligature.  The  difficulties  are  increased  when  the  distance  between 
the  tumor  and  the  transverse  colon  is  so  short  that  there  is  but  little  room  to 
woi-k  between  the  two.  In  one  case  the  whole  omentum  had  disappeared,  leav- 
ing the  colon  spread  out  flat  on  the  surface  of  the  tumor,  and  sending  a  number 
of  large  vessel*  into  its  substance.  This  difficulty  was  met  by  cutting  off  a  thin 
shell  of  the  capsule  of  the  tumor  circumscribing  the  vascular  area,  and  then  fold- 
ing it  in  upon  itself,  and  sewing  the  edges  of  the  strip  together. 

(i.  Parietal  Adhesions . — Adhesions  to  the  abdominal  walls  are  not 
common,  and  when  they  do  occur,  usually  form  an  unimportant  complication. 
The  worst  adhesions  I  have  ever  seen  of  this  kind  were  in  a  case  of  a  large 
fibroid,  in  which  electricity  had  been  used  for  a  long  time.  Just  under  the  places 
where  the  electric  pads  had  been  applied  on  the  right  and  left  sides  the  adhe- 
sions over  areas  about  10  bv  12  centimeters  were  the  densest  I  have  ever  seen  ; 


378  *  MYOMECTOMY — HYSTERO-M  YOMECTOMY. 

two  enormous  arteries  from  3  to  4  millimeters  in  diameter  coursed  prominently 
under  the  peritoneum  from  the  lower  abdomen  to  the  adherent  areas.  The 
difBculty  of  detaching  the  tumor,  which  at  first  bid  fair  to  be  serious,  from  the 
constant  extensive  capillary  oozing,  was  overcome  by  ligating  these  arteries  in 
their  course  low  down  in  the  abdomen,  and  by  obliterating  with  buried  sutures 
the  raw  areas  left  after  detaching  the  tumor. 

In  rare  instances  the  myoma  filling  the  pelvis  forms  adhesions  to  the  pelvic 
floor,  and  the  chief  difficulties  in  the  operation  may  arise  from  the  constant  ooz- 
ing from  numerous  small  vessels  in  the  thickened  pelvic  peritoneum  at  a  point 
quite  remote  from  the  surface.  The  best  w^ay  to  control  the  bleeding  is  to  lift 
up  the  peritoneum  so  as  to  make  a  fold  and  then  to  suture  one  fold  to  another 
until  the  bleeding  points  are  all  under  control. 

7.  Intestinal  Adhesions  . — The  sigmoid  flexure  is  more  likely  to  ad- 
here to  a  tumor  than  any  other  part  of  the  intestine,  and  it  is  commonly  found 
attached  to  the  top  of  the  broad  ligament  and  the  tumor  adjacent  to  it.  Its 
separation  is  easily  effected  by  lifting  it  up  and  dissecting  it  carefully  off  from 
the  vessels  below,  which  are  plainly  seen. 

The  rectum  rarely  gives  any  trouble  from  adhering  directly  to  the  tumor ; 
it  is  more  a]3t  to  become  attached  to  the  inflamed  lateral  structures.  Adhesions 
to  tlie  rectum  low  down  in  the  pelvis  may,  as  a  rule,  be  safely  left  undisturbed. 

The  colon  and  small  intestines  do  not  often  adhere.  When  they  do,  if  the 
separation  can  not  be  made  easily  by  drawing  up  the  bowel  and  forming  a  little 
interval  in  the  connective  tissue  binding  the  structures  together,  which  can  be 
safely  cut  through,  then  the  imj^ortant  principle  is  to  sacrifice  the  cajj- 
s u  1  e  of  the  tumor  to  the  bowel  by  dissecting  off  a  piece  around  the 
attached  area. 

There  is,  however,  one  kind  of  myomatous  uterus  of  which  I  have  seen  two 
examples,  where  the  pelvic  adhesions  are  universal,  and  the  small  intestines 
wherever  they  touch  it  are  so  firmly  agglutinated  that  separation  is  entirely  out 
of  the  question.  I  opened  the  abdomen  in  one  of  these  cases  four  years  ago, 
and  concluded,  from  the  red  vascular  appearance  of  the  softish  mass  covered 
with  lymph  and  adherent  bowels,  that  the  tumors  were  malignant ;  the  patient 
recovered  from  the  exploratory  incision  and  is  in  fair  health  to-day.  I  know  of 
no  way  of  reaching  these  cases. 

8.  Adhesions  to  the  Vermiform  Appendix . — When  the  appen- 
dix adheres  to  the  tumor,  a  light  adhesion  may  be  peeled  off,  but  if  the  adhesion 
is  dense,  or  if  there  is  evidence  of  a  coexisting  appendicitis,  the  best  plan  is  to 
free  the  tumor  on  the  left  side,  cut  across  the  cervix,  clamp  the  right  uterine 
artery  and  roll  the  tumor  out,  and  then  when  the  right  round  ligament  and 
ovarian  vessels  are  secured,  to  clamp  off  the  appendix  near  the  colon,  leaving  it 
attached  to  the  tumor.  The  stump  of  the  appendix  is  then  dealt  with  as  de- 
scribed in  Chapter  XXXVI, 

9.  Adhesions  to  the  Liver  and  its  Sus])ensory  Ligament. 
— This  complication  existed  in  one  of  my  cases — a  large  nodular  fibroid  uterus 
filling  the  abdomen.     The  suspensory  ligament  bled  freely,  but  the  flow  was 


COMPLICATIONS    OF    HYSTERO-M YOMECTOMY. 


379 


easily  controlled  by  gathering  the  bleeding  areas  together  by  a  catgut  suture. 
Liver  adhesions  may  be  treated  by  passing  sutures  below  the  bleeding  points 
and  tying  them  carefully,  tight  enough  to  stop  the  flow,  but  not  tight  enough  to 
cut  into  the  liver  tissue. 

Tumors  of  the  Ovary  complicating  Fibroid  Uteri . — 10. 
Ovarian  cystoma.  11.  Dermoid  cyst.  12.  Fibroid  ovary.  13.  Ovarian  hydro- 
cele.    14.  Hematoma  of  the  ovary. 

I  have  met  each  of  these  conditions  as  complications  of  hystero-myomectomv. 
The  first  three  are  rare  and  merely  accidental  complications ;  the  fourth  is,  I 
believe,  unique.  The  fifth  con<lition  is  frequently  met  with,  either  one  or  both 
ovaries  containing  a  large  hematoma  developing  from  the  corpus  luteum. 

The  best  plan  of  operating  is  to  remove  the  ovarian  tumor  and  the  fibroid 
uterus  together.  If  the  ovarian  tumor  has  a  long  pedicle,  this  may  be  simply 
clamped  and  the  cyst  taken  away  first ;  and  if  it  is  so  large  as  to  be  unwieldy, 
it  may  be  emptied  before  taking  it  out  together  with  the  uterus.  The  picture 
shows  a  large  ovoid  fibroid  uterus  with  large  dermoid  cysts  of  the  left  ovary  in 
a  patient  (J.  Q.,  3250)  operated  on  Dec.  29,  1894 ;  the  whole  was  removed  in 
one  large  mass.  These  operations  are  difficult  only  on  account  of  the  awk- 
wardness of  handling  the  tumors ;  their  percentage  of  mortality  ought  not  to 
be  greater  than  that  of  simple  hystero-myomectomy. 


Fig.  502.— Globular  Myomatois  Dteiu-s  complicated  by  Dermoid  Cy.<5T9  or  the  Left  Ovary. 
Hystero-myomectomy.    Becovery.    Dec.  12, 1894.    Longest  diameter  32  centimeters.    %  natural  size. 


15.  Carcinoma  of  the  Ovary. — I  have  seen  three  cases  of  a  cancer 
of  the  ovary  complicating  a  large  fibroid  tumor  of  the  uterus.  In  one  of  these 
cases  the  pelvic  peritoneum  was  the  seat  of  numerous  little  sprouting  cancerous 
areas,  disseminated  from  tlie  ovaries.  The  myomatous  uterus  was  as  large  as 
a  five  months'  pregnancy.  I  took  out  both  ovaries  and  uterus  and  evacuated  a 
large  amount  of  ascitic  fluid.  The  patient  recovered,  but  died  six  months  later 
with  ascites  and  large  carcinomatous  masses  filling  the  abdomen. 


380  MYOMECTOMY — HYSTERO-MYOMECTOMY. 

Another  case  was  that  of  a  colored  woman  (E.  M.,  Path.  No.  1009,  operated 
upon  Dec.  11,  1895),  with  a  large  myoma  filling  the  lower  abdomen  and  rising 
above  the  umbilicus,  with  ascites.  The  bladder  was  adherent  high  up  on  the 
anterior  face,  and  on  the  right  side  there  was  a  large  carcinomatous  mass  filling 
the  right  posterior  quadrant  and  extending  back  behind  the  rectum.  The  ex- 
tirpation was  made  from  left  to  right  in  the  usual  way,  and  after  exposing  the 
cancerous  mass  from  the  front  of  the  right  broad  ligament  it  was  shelled  out  of 
its  bed  and  the  enucleation  continued  up  behind  the  rectum,  taking  away  a  good 
handful  of  carcinomatous  tissue  in  all.  A  number  of  enlarged  glands  were  felt 
behind  the  rectum  and  the  lower  part  of  the  sigmoid  flexure,  making  a  perma- 
nent recovery  hopeless. 

Diseases   of   the    Cervix   and    Uterine   Mucosa. 

16.  C a n c e r  of  the  Cervix  complicating  Myoma . — In  rare 
instances  cancer  of  the  cervix,  cancer  of  the  uterine  mucosa,  sarcoma,  and  tuber- 
culosis of  the  endometrium  have  been  found  complicating  myoma  of  the  uterus. 
When  the  myomata  are  insignificant  in  size  and  the  tuberculosis  or  the  neoplasm 
is  found  in  an  advanced  stage,  the  myoma  may  be  looked  upon  simply  as  a  com- 
plication of  the  latter.  I  refer  here,  however,  to  instances  in  which  the  promi- 
nent clinical  symptoms  are  due,  or  have  seemed  to  be  due,  to  the  myomatous 
condition  and  the  neoplasm  has  not  progressed  far.  Cancer  of  the  cervix  may 
be  discovered  upon  making  a  vaginal  examination  to  determine  the  size  and  re- 
lations of  the  enlarged  uterus ;  the  other  conditions,  however,  are  not  apt  to  be 
suspected  unless  the  uterine  mucosa  is  curetted  and  a  microscopic  examination 
is  made. 

As  a  rule,  cancer  cells  are  found  only  when  the  specimens  removed  are  sub- 
jected to  a  thorough  examination.  In  all  such  instances  panhysterectomy  is  indi- 
cated ;  in  the  event  of  the  discovery  after  the  operation,  the  cervix  should  be  taken 
out  by  the  vaginal  route  when  the  patient  has  recovered  from  her  first  operation. 

17.  Cancer  of  the  Uterus  associated  with  Myomata. — 
When  we  recall  the  large  number  of  cases  of  myomata  we  are  called  upon  to 
treat,  and  of  the  frequency  of  cancer  of  the  uterus,  it  would  be  surprising  if 
the  one  were  not  at  times  associated  with  the  other.  The  liability  of  myomatous 
uteri  to  cancer  is,  however,  manifestly  lessened  by  the  fact  that  the  patient  is 
often  sterile  and  the  cervix  is  spared  the  traumata  of  parturition  which  afford 
an  anatomical  basis  for  the  cancer.  For  the  sake  of  conciseness  I  divide  these 
cases  into  three  groups  : 

(1)  Epithelioma  of  the  cervix  associated  with  myoma. 

(2)  Adeno-carcinoma  of  the  cervix  and  myoma. 

(3)  Adeno-carcinoma  of  the  body  of  the  uterus  with  myoma. 

In  a  review  of  one  hundred  cases  of  carcinoma  of  the  uterus,  occurring  in 
my  wards  at  the  Johns  Hopkins  Hospital,  eight  cases  were  associated  with 
myomata,  one  case  with  epithelioma,  one  case  with  adeno-carcinoma  of  the  cer- 
vix, and  six  cases  with  adeno-carcinoma  of  the  body. 

In  the  patient  with  the  epithelioma  of  the  cervix  the  myoma  was  small  and 
was  not  discovered  until  after  removal  of  the  organ. 


Fio.  503. — Myoma  and  CAKCiNOiiA  in  a  Negress. 

Showing  the  zoned  occupied  by  preference  by  the  two  forms  of  disease.  The  fundus  is  converted  into  a 
■mass  of  myomatous  podulcs  while  the  entire  lower  segment  of  the  uterus  haz  been  replaced  by  carcinomatous 
vegetations.  There  are  meta.stases  in  the  inguinal  glands  as  large  as  an  ce;g.  The  disease  e.xtends  through 
the  broad  ligaments  to  the  bladder;  metastases  also  exist  in  the  mesenteric,  retro-peritoneal,  and  bronchial 
glands,  as  well  as  iu  the  lungs,  pleura,  and  serosa  of  the  intestines.  There  is  an  anemia  of  all  the  organs  and 
a  fatty  degeneration  of  the  liver.  Hydroureter.  The  myomata  are  not  involved  in  the  carcinomatous  process. 
Ho.  926.    Autopsy,  March  29, 1897.    "/t  natural  size. 


COMPLICATIONS    OF    HYSTERO-MYOMECTOMY. 


381 


In  the  adeno-carcinoma  of  the  cervix  there  were  multiple  myomata  scattered 
throughout  the  uterus.  The  majority  of  the  cases,  six  out  of  eight,  where  the 
carcmoma  was  present  with  myoma,  were  adeno-carcmomata  of  the  body.  The 
myomata  were  in  some  instances  subperitoneal,  in  others  interstitial,  while  in 
one  case  a  small  submucous  nodule  was  present.  Probably  one  of  the  most  in- 
teresting cases  was  one  of  primary  carcinoma  of  the  ovary.  The  uterus  was 
secondarily  involved,  and  not  only  was  the  muscle  penetrated  in  all  directions 
by  the  new  growth,  but  a  large  and  degenerate  myoma  showed  carcinomatous 
invasion  in  numerous  places.  Although,  as  has  been  seen,  carcinoma  of  the 
uterus  is  at  times  associated  with  myomata,  the  two  diseases  represent  two  dis- 


Fi<;.  504.— Myoma  -with  Cvstic  Degeneration. 

Large  cavity,  6x4-5x5  centimeters,  filled  with  liquid  resemblincr  melted  butter.  The  tumor  i.s  imbedded 
in  7  millimeters  of  the  uterine  muscular  tissue,  and  its  walls  are  made  up  of  interlacing  non-striated  muscu- 
lar fibers.  No  inflammatory  changes  found.  Hystero-myomectomy.  Kccovury.  Tath.  No.  347.  Vj  natu- 
ral size. 


tinct  processes,  in  no  way  dependent  the  one  upon  the  other,  and  the  presence 
of  the  one  does  not  appear  to  alter  the  characteristic  course  of  the  other. 

18.  Tuberculosis  of  the  En  d  om  etri  u  m  .—Tuberculosis  of  the 
endometrium  is  exceedingly  rare  as  a  complication  in  the  large  myomatous 
uterus.  1  have  met  with  but  one  case,  and  in  this  the  disease  was  not  recogniz- 
able to  the  naked  eye,  but  was  readily  shown  by  a  microscopic  examination  occu- 
pying the  entire  mucosa ;  it  extended  out  into  both  tubes,  which  were  nodular 
and  caseous  but  showed  no  breakiuic  down.     A  piece  removed  from  this  case 


382 


MYOMECTOMY — HYSTERO-MYOMECTOMY. 


was  used  for  the  plate  illustrating  tuberculosis  of  the  endometrium,  Vol.  I, 

p.  489. 

Complications  due  to  Changes  in  the  Tumors  Them- 
selves.— There  are  three  principal  complications  due  to  alterations  in  the 
tumors  ;  these  are  cystic,  vascular,  and  suppurative  changes. 

19.  C  y  s  t  o  -  m  J  o  m  a . — The  cystic  change,  as  a  rule,  does  not  in  any  way 
add  to  the  difficulties  of  operating.  Cystic  fibroids  may  be  perfectly  free  and 
are  as  easily  extirpated  as  a  solid  tumor,  as  will  be  seen  by  looking  at  the  fig- 
ures ;  some  cases,  on  the  other  hand,  show  a  tendency  to  form  intimate  attach- 
ments on  all  sides,  and  here  the  difficulties  arise  from  the  adhesions.  I  had  one 
case  of  this  kind  where  the  cystic  tumor  choked  the  pelvis  and  was  everywhere 
so  densely  adherent  that  I  was  unable  to  remove  it ;  I  tapped  the  cysts  through 
the  vagina  several  times,  removing  3  or  4  liters  at  each  tapping ;  the  patient 
finally  died  of  exhaustion  from  the  pressure  on  the  viscera. 


Fig.  505. — L.\uge  Fibro-cystic  Tlmor  of  the  Uterus  attached  by  a  Broad  Pedicle  to  a  Multi- 
nodular MY'oaiATou.s  Uterus. 

The  right  uterine  tube  is  seen  in  the  angle  above  between  the  liBro-cy.st  and  the  uterus.     The  hyper- 
trophied  ovary  is  seen  on  the  left  side,     ilystero-myouiectomy.     Eeeovery.     Jan.,  1895.    %  natural  size. 

20.  Telangiectatic  Myoma . — The  telangiectatic  myoma  is  awkward 
to  handle  on  account  of  the  great  venous  sinuses  leading  out  of  it,  as  well  as  the 
enormous  venous  tracts  within,  any  one  of  which  if  wounded  would  immediately 
deluge  the  field  of  operation  with  blood.  A  beautiful  example  of  this  kind  of 
myoma  is  shown  in  section  in  the  colored  Plate  XX,  where  the  dark  vascular 
areas  and  the  mouths  of  the  cut  vessels,  which  are  mostly  arteries,  are  plainly 
seen  in  patches.  At  other  places  lymph  is  seen  coagulated  in  the  tissues  between 
tlie  myomatous  nodules.  A  tumor  of  this  class  often  resembles,  on  section,  a 
large  vascular  sponge. 

21.  Suppurating  Myoma. — I  refer  under  this  head  to  certain  rare 
cases  in  which  the  myomatous  tumor  forms  a  shell  filled  with  pus.  I  do  not  in- 
clude here  those  sloughing  submucous  tumors  which  discharge  fer  vaginam. 


11  :     :>nB  ,■:•),..-    .'1 


^o 


DESCRIPTION  OF  PLATE  XX. 

ANGIO-MYOMA  OP  THE  UTERUS,   WITH  CYSTIC  DEGENERATION, 

The  tumor  has  been  divided  lengthwise,  and  the  picture  shows  one  side  of  the  cut 
surfaces ;  the  uterine  muscle  is  seen  retracted  on  the  right  side,  and  the  myomatous 
nodules  stand  out  prominently. 

The  groups  of  cysts  scattered  throughout  the  tissue  are  those  usually  seen  in  myo- 
mata  undergoing  cystic  changes.  The  bluish  areas  are  the  most  important  and  strik- 
ing features  of  the  picture ;  they  are  cross-sections  of  groups  of  blood  vessels,  some  of 
which  consist  of  as  many  as  one  hundred  vessels.  Histologically,  they  are  found  to 
be  arteries.  The  rest  of  the  myoma  is  divided  into  innumerable  lobules  and  presents 
the  usual  appearance. 


i_/  V  I    i_^  .'v\ 


OF  PLATE  XX. 

ANGIOMYOMA  OF  THJR  UTKRU8,   WITH  CYSTIC  LKGENKRATION, 

The  tumor  has  been  divided  leufftli\\  ise,  and  the  picture  shows  one  side  of  the  cut 

iMjted  on  the  riglit  side,  and  the  myomatous 

T.  those  usually  seen  in  myo- 

i*  _.-..;  most  importmt  and  str-ik- 

of  groups  of  blood  vessels,  some  of 
,r:.   1       -.,i„    .1  ^  found  to 

.  presents 


V  i^r\  1    L^  /vy\ 


MBririel.fT 


Lth.LPran«*CaBo3tf 


COMPLICATIONS   OF   HYSTEKO-MYOMECTOM Y.  383 

Such  a  case  (A.  S.,  3210,  Dec.  3,  1894)  is  figured  in  the  text ;  the  patient 
had  a  large  intrahgamentary  mass  on  the  right  side  with  septicemia,  and  came 
to  the  clinic  exceedingly  prostrated.     (See  Fig.  511.) 

The  tumor  had  formed  dense  parietal  adhesions  and  the  omentum  was  at- 
tached by  its  entire  free  border,  together  with  the  cecum,  colon,  and  small 
intestines  on  the  right  side. 


•^     /     «     cl     d     e     ^  ■^"^^'^- 

Fig.  506. — Torsion  of  the  Globular  Myomatous  Uterus  from  Left  to  Kigiit,  rringing  the  Fundus  to 
THE  Front  and  the  Right  Tube  and  Ovary  around  to  the  Left  Side. 

Tlie  tumor  occupies  the  entire  anterior  uterine  wall.    Operation.    Recovery.    %  natural  size.    Jan.  9, 1S97. 

An  incision  into  the  al)domen  was  made  Ifi  centimeters  ((*)  inches)  long,  the 
fluctuating  myoma  tapped,  and  4,700  cubic  centimeters  of  yellow  pu.s  removed. 
The  great  difficulties  on  the  right  side  were  met  by  first  cutting  through  the  left 
broad  ligament  and  amputating  the  uterus,  and  then  clamping  the  right  uterine 
artery  just  as  described  in  the  typical  operation.     As  the  uterus  and  the  big  col- 


384 


MYOMECTOMY — HYSTERO-MYOMECTOMY. 


lapsed  tumor  were  rolled  up  and  out,  the  adherent  intestines  were  approached  from 
below  and  easily  separated.  The  omentum  was  tied  off,  and  the  dense  abdomi- 
nal-wall adhesions  treated  by  leaving  on  a  plaque  dissected  from  the  outside  of 
the  tumor.     The  patient  recovered  and  was  in  good  health  a  year  later. 

These  cases  are  also  quite  distinct  from  those  in  which  there  is  a  suppurative 
endometritis ;  I  have  seen  one  case  in  which  thei-e  existed  a  pyometra,  the  uter- 
ine cavity  containing  about  40  cubic  centimeters  of  pus.  It  is  on  account  of 
this  complication  that  it  is  so  important  to  cover  up  the  uterine  cavity  as  soon  as 
it  is  incised  to  avoid  contamination  of  the  wound. 

22.  Cystic  Myoma  Uteri  with  Twisted  Pedicle.  —  Myo- 
matous tumors  stand  in  remarkable  contrast  to  ovarian  tumors  as  regards  the 
rarity  with  which  a  twisted  pedicle  is  found.     Either  the  myoma  may  be  pedun- 


?<xrC   of  cervix 
thai  was  twisted 


Cervix 


Fio.  507. — Torsion  of  the  Myomatous  Uterus.     The  Uterus  seen  in  Fig.  506  Untwisted. 

Showing  the  knoblike  cervix  and  the  thinned-out  supravaginal  cervix.    Seen  from  above  and  from  be- 
hind the  uterus. 


culate  and  twist  and  contract  adhesions,  or  the  body  of  the  uterus  with  a  large 
myoma  of  the  spherical  sort  may  be  revolved  on  the  thinned-out  cervix  and  the 
broad  ligament  as  a  pedicle,  as  shown  in  the  accompanying  illustrations  (see  Figs. 
506  and  507). 

Lesser  degrees  of  torsion,  as,  for  example,  a  quarter  of  a  turn,  are  not  infre- 
quently seen,  and  are  due  to  slight  movements  of  accommodation  of  the  con- 
tained body,  the  uterus  with  its  tumors,   to    the   containing  body,   the   lower' 


PLATE  XXI. 


MBrbdel.fec. 


HeUotype  Frinting  Co,  Bosto 


DESCRIPTION  OP  PLATE  XXI. 

BENIGN  ADENO-MYOilA  OF  THE  UTERUS. 

The  uterus  cut  open  and  viewed  from  the  front.  A  spherical  myoma  fills  the  cer- 
vical end,  and  is  everywhere  penetrated  by  glands.  The  divided  anterior  uterine  wall, 
enormously  thickened,  is  made  up  of  three  layers ;  the  inner  layer  is  the  uterine 
mucosa,  presenting-  a  smooth,  slig-htly  undulating'  surface ;  the  outermost  layer  con- 
sists of  parallel  bundles  of  normal  uterine  muscular  tissue,  and  between  these  two 
layers  is  one  which  presents  a  coai'sely  reticular  appearance,  everywhere  penetrated 
by  the  uterine  glands,  which  extend  as  far  as  the  outer  muscular  layer. 


COMPLICATIONS    OF    HYSTERO-MYOMECTOMY.  385 

abdominal  cavity.  If  the  containiao-  l)ody  is  often  changing  its  shape  and  is 
often  shaken  up,  as  is  the  case  with  the  abdominal  cavity,  it  is  manifest  that  the 
contained  body  will  sooner  or  later  find  the  bed  which  best  fits  its  form. 

The  following  case  is  an  example  of  the  torsion  of  a  cystic  myoma  on  its 
pedicle : 

A,  Y.,  4:485,  white,  aged  thirty-nine,  first  noticed  an  abdominal  enlargement 
in  1895,  which  increased  gradually  for  four  months,  when  she  began  to  swell 
rapidly.  She  had  not  suffered  any  pain  and  only  comj)lained  of  a  smothermg 
sensation  and  shortness  of  breath.  Upon  making  a  vaginal  examination  the 
cervix  was  found  buried  in  a  mass  extending  up  into  and  filling  the  abdomen  ; 
the  abdomen  was  symmetrically  distended,  with  flabby  thick  walls,  presenting  a 
distinct  wave  of  fluctuation,  but  a  tumor  could  not  be  distinctly  outlined. 

Operation,  July  2,  1896,  hystero-myomectomy.  On  opening  the  peritoneal 
cavity,  the  intestines  were  exposed  and  found  resting  upon  a  cystic  myoma, 
springing  from  the  right  cornu  of  the  uterus  and  completely  filling  the  lower 
abdominal  cavity,  and  looking  like  a  large  multilocular  cystoma.  The  cyst  wall 
was  hemorrhagic  and  flabby,  so  that  the  tumor  lay  like  a  half -filled  bladder  upon 
the  posterior  abdominal  wall.  Many  of  the  spaces  contained  dark,  bloody  fluid ; 
a  few  of  them  contained  clear  serum.  To  the  left  and  above  the  umbilicus  the 
tumor  was  intimately  adherent  to  the  anterior  abdominal  wall.  The  pedicle, 
which  was  about  -4  centimeters  long,  had  two  distinct  twists  from  left  to  rio-ht. 
The  adhesions  to  the  abdominal  wall  wei-e  freed  and  the  pedicle  cut  off  close  to 
the  uterus.  A  few  catgut  ligatures  controlled  the  hemorrhage.  The  uterus  was 
symmetrically  enlarged  to  the  size  of  a  three  months'  pregnancy,  and  on  both 
sides  a  large  adherent  hydrosalpinx  was  found.  Hystero-salpingo-oophorectomy 
was  then  ])er formed  by  a  continuous  incision  from  left  to  right  without  difli- 
culty,  and  the  patient  made  an  uneventful  recovery. 

23.  A  d  e  n  o  -  m  y  o  m  a  Uteri  D  i  f  f  u  s  u  m  B  e  n  i  g  n  u  m  . — In  the  Johns 
Ilopk.  Hosj).  liej}.,  vol.  vi,  p.  133,  Dr  T.  S.  Cullen  describes  one  of  my  cases  con- 
stituting a  new  variety  of  myoma  under  the  name  of  "  adeno-myoma  uteri  dif- 
fusum  benignum."  I  have  also  had  two  more  cases  during  the  past  year.  These 
adeno-myomata  are  rather  more  interesting  from  the  pathological  than  from  the 
<'linical  standpoint,  because  their  true  character  can  not  be  recognized  before 
operation,  as  the  s^-mptoms  do  not  differ  from  those  of  simple  myomata. 

The  treatment  differs  in  that  they  can  not  be  enucleated  like  the  simple 
myomata  on  account  of  the  intimate  connection  of  the  tumor  with  the  uterine 
muscle. 

The  only  operation,  therefore,  which  can  be  done  in  these  cases  is  hystero- 
myomectomy. 

Case  I. — Adeno-myoma  uteri  diffusum  benignum.  (t  1  a  n - 
d  u  1  a  r  uterine  polyp  i  n  c  e  r  v  i  x .  Small  interstitial  and  sub- 
peritoneal  myomata.     (Plates  XXI  and  XXII.) 

L.  AV.,  admitted  to  my  service,  Oct.  24,  1894,  aged  forty-six,  single. 

Her  complaint  on  admission — pain  in  lower  part  of  abdomen,  painful  and 
profuse  menstruation.     Menstruation  commenced  when  she  was  eleven  yearf.  of 


386  MYOMECTOMY — HYSTERO-MYOMECTOMY. 

age,  and  was  always  regular.  For  tlie  past  ten  years  she  has  had  severe  pains  in 
the  right  ovarian  region  at  the  menstrual  period.  These  pains  radiated  down 
both  limbs,  were  accompanied  by  backache,  and  for  the  last  two  years  have  been 
so  severe  that  she  has  been  confined  to  bed  for  from  three  to  four  days  at  each 
period.  At  present  the  flow  lasts  from  ten  days  to  two  weeks,  and  there  is  a  con- 
siderable amount  of  clotted  blood.  Her  last  period  ceased  one  week  before 
admission.  Her  parents  are  both  living  and  healthy.  One  brother  died  of 
tuberculosis.  With  the  exception  of  an  attack  of  diphtheria  several  years  ago, 
and  influenza  three  years  ago,  she  has  always  been  well. 

Present  Condition  . — The  patient  is  a  rather  anemic  woman  and  does 
not  appear  to  be  strong.  Her  tongue  is  pale  and  flabby,  appetite  fair,  bowels 
regular.     She  is  unable  to  walk  much  and  can  not  lift  heavy  weights. 

Vaginal  Examination . — The  outlet  is  much  relaxed,  and  presenting 
at  the  oi-ifice  is  a  hard,  irregular  mass,  which  proves  to  be  the  cervix.  The 
external  os  is  patulous,  admitting  the  index  finger,  and  projecting  from  the  os 
is  what  appears  to  be  a  myomatous  nodule  about  the  size  of  a  hazelnut.  The 
cone-shaped  cervix  is  continuous  with  the  enlarged  uterus,  which  is  apparently 
freely  movable. 

Clinical    Diagnosis . — Myoma  corporis  uteri. 

Operation,  Oct.  31,  1894.  On  opening  the  abdomen  it  was  found  impossible 
to  raise  the  uterus  out  of  the  pelvis,  and  the  operator  was  compelled  to  work  in 
the  narrow  space  between  the  utenis  and  the  pelvic  walls.  The  ovarian  and 
uterine  vessels  on  both  sides  were  controlled  and  the  uterus  amputated.  The 
lips  of  the  stump  were  then  brought  together,  and,  lastly,  the  peritoneum  from 
the  posterior  wall  sutured  to  that  of  the  anterior,  thereby  completely  covering 
over  the  stump.  The  patient  made  an  uninterrupted  recovery,  and  was  dis- 
charged Dec.  1st. 

Pathological  Report  (No.  497). — The  specimen  consists  of  the  en- 
larged uterus  with  its  tubes  and  ovaries  intact.  The  uterus  is  13  centimeters 
long,  12  centimeters  broad,  and  10  centimeters  in  its  antero -posterior  diameter. 
It  is  approximately  globular,  and  in  its  contour  resembles  a  normal  but  enlarged 
uterus.  Anteriorly  it  is  smooth  and  glistening,  posteriorly  over  its  lower  two 
thirds  it  is  denuded  of  peritoneum.  Situated  in  the  posterior  wall  in  the  vicinity 
of  the  left  uterine  cornu  are  four  sessile  nodules,  which  are  approximately  cir- 
cular. The  largest  of  these  is  2  centimeters  in  diameter.  On  section  they  are 
whitish  in  color  and  are  composed  of  fibers  concentrically  arranged.  They  pre- 
sent the  usual  myomatous  picture.  The  undercut  surface  of  the  utenis  is  12  by 
11  centimeters.  In  the  center  of  this  is  the  cervical  opening,  which  is  1  centi- 
meter in  diameter.  Projecting  from  the  right  side  of  this  opening  is  a  nodule 
2'5  centimeters  in  diameter ;  this  is  apparently  covered  by  mucous  membrane 
which  is  somewhat  hemorrliagic. 

The  anterior  uterine  wall  is  7  centimeters  in  thickness 
(Plate  XXI) ;  it  can  be  divided  into  two  distinct  portions  —  an 
outer  one,  1  centimeter  t  h  i  c  k  ,  w  li  i  c  h  resembles  normal  uter- 
ine muscle;  the  remainder   of  the  wall  presents  a  coarsely 


PLATE 


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Tnmnr  rousistiiig  of  TnvomiiinvLs  imii-.fle  and  uu-rm'-  ,iil;Miils 


Normal  uterine  ninsde. 


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Helioiype  Priming  Co,  Boston 


DESCRIPTION  OF  PLATE  XXII. 

BENIGN  ADENO-MYOMA  OP  THE   UTERUS. 

The  long  section  is  taken  from  Plate  XXI  and  magnified  four  times.  To  the  left  is 
the  uterine  mucosa  with  a  wavy  outline,  intact  svirface  epithelium  and  glands  mostly 
normal ;  a  few  glands  are  dilated.  Below  the  mucosa — that  is,  to  the  right  in  the  pic- 
ture— the  glands  are  seen  extending  all  the  way  through  to  the  normal  uterine  muscle 
on  the  extreme  right ;  they  penetrate  the  pale  muscular  bundles,  and  are  surrounded 
with  a  darker  area  of  typical  stroma  of  the  mucosa.  This  irregular  muscular  area  also 
contains  numerous  dilated  gland  spaces.  Occasional  dark  patches  without  lumina  are 
made  up  of  stroma  devoid  of  glands. 

The  lower  figure  shows  a  cross-section  of  the  gland,  seen  at  a  in  the  upper  figure, 
magnified  two  hundred  times.  The  gland  is  lined  by  one  layer  of  cylindrical  epithe- 
lium, and  is  surrounded  by  cells  having  oval  vesicular  nuclei ;  it  is  identical  in 
appearance  with  a  normal  uterine  gland.  Surrounding  the  stroma  of  the  gland  are 
non-striped  muscular  fibers,  for  the  most  part  cut  longitudinally. 


.iixx  aTAJ*i  '?o  >ioiT^iaos3a 

.suflaru  3HT  ■?<)  AMOYK-o'»5aaA  vioreaa 

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•\jlJ8oai  sbasl-g  bae  muilediiq^  soiil'iua  iojaitti  ,9aiUuo  ^vf-w  fi  xIJit/  Baooum  atuiaiu  eili 
-oiq  erli  ni  id-g'n  edi  oi  .ai  JBiiJ — £^oouai  adi  woIaS  .baJelib  &i&  isbnfil^a  wal  ii  ;  laaiion 
eloBjjm  enhaJjj  iBinion  sxU  oi  d-^i^ucndi  x^vr  grfi  !!«  ^niLnaJxa  xioaa  9*ixj  shn^I^  erli — e-uij 
bobnuoTiua  6»ib  bnc  ,^f^\htiud  inl;  r^atii  ofnq  '>dJ  -^  "•  Jrf^i'i  a/ui^'iixa  sdi  (!<> 

9TB  Bnimwl  ijjodjm  eadoiBq  jf'mb  iiinoia^oO     .fesoBqa  bmiiji  ijo;t;iib  euo'iemun  aniijiii- 

>••>■,   '^  '<•.  i  ■<--,'•.■>  iiiiiotit  \o  qiT  sbiJiii 
,9iu^B  laqqjj  edi  ni  »  ifi  flssg  ,i  .nsfl  a-jwol  adT 

-adJiqa  iBoiibnil-^o  ^O'lsxnl  ^iu>  ly  ii^Jiiii  ^i  oiiBh^  oru  .^-Jinii  ;>'>'  lud  owJ  bBiYiiV^iAn 
ni  iBobnabi  ai  ii  ;  ialoun  •>f:rn'.i?,«»v  Ibvo  ^uivaif  sllao  vd  babnjjormg  pj  bnB  ,fni'i! 
91B  bflfil's  ari;t  lo  Braoiia  ^.  "onrw^     .bnal'g  oahaJu  iBrmoir  b  d:tiv/  o- 

."^IIb;!  1  i;-o  J'iBq  Ji*orit  9ifJ -lot  .»'i9drl  iBluoswin  b'  ^ 


COMPLICATIOXS    OF    HySTERO-MYOMECTOMY.  387 

striated  appearance,  the  striae  running  in  all  directions. 
Scattered  throughout  this  thickened  and  striated  portion  of  the  uterine  wall  are 
round,  oval,  or  elongate,  brownish-yellow,  homogeneous  areas,  some  of  which 
merge  directly  into  the  uterine  mucosa.  In  one  or  two  places  small  cysts,  vary- 
ing from  1  to  4  millimeters  in  diameter,  can  be  seen  scattered  throughout  this 
thickened  portion  of  the  uterine  wall.  The  striated  appearance  can  be  traced 
directly  up  to  the  uterine  mucosa,  and  in  some  places  into  it.  After  hardening 
the  specimen  in  Miiller's  fluid  the  contrast  is  sharp  between  the  normal  uterine 
muscle  and  the  thickened  striated  portion,  the  uterine  muscle  being  much  darker 
in  color  than  the  striated  portion.  The  posterior  wall  of  the  uterus  varies  from 
2*5  to  3"5  centimeters  in  thickness.  It  is  rather  dense,  but  does  not  present  any 
coarse  striation.  Situated  in  the  posterior  wall  are  two  interstitial  nodules  1 
and  1*5  centimeter  in  diameter  ;  they  are  pearly  white  in  color  and  are  com- 
posed of  concentrically  arranged  fibers. 

The  uterine  cavity  is  7*5  centimeters  in  length,  and  at  the  upper  part  8  cen- 
timeters in  breadth.  The  mucous  membrane  of  the  anterior  uterine  wall  varies 
from  7  to  8  millimeters  in  thickness,  is  yellowish  white  in  color,  smooth  and 
glistening.  In  many  places,  however,  it  presents  ecchymoses  in  the  super- 
ficial portions.  In  the  vicinity  of  the  internal  os  and  extending  upward  for 
about  2'5  centimeters  are  three  or  four  longitudinal  folds  of  the  mucosa.  The 
depression  between  these  are  about  4  or  5  millimeters  in  depth.  The  mucosa 
covering  the  posterior  wall  varies  from  3  to  4  millimeters  in  thickness. 

Right  Side . — The  uterine  tube  is  11  centimeters  long  and  averages  7 
millimeters  in  diameter.  Its  fimbriated  extremity  is  patent ;  the  parovarium  is 
intact.  The  ovary  measures  8  X  2'5  X  1"5  centimeters,  is  pale  white  in  color, 
smooth  and  glistening.  It  contains  two  corpora  lutea,  the  larger  of  which  is 
2*5  centimeters  in  diameter. 

Left  Side. — The  uterine  tube  is  9  centimeters  long  and  6  millimeters  in 
diameter.  Its  extremity  is  patent ;  the  parovarium  is  intact.  The  ovary,  4  X 
4x1  centimeter  in  size,  is  yellowish-white  in  color  and  somewhat  lobulated. 
It  contains  a  cyst  2'5  centimeters  in  diameter.  The  walls  of  this  are  2  milli- 
meters in  thickness,  and  the  inner  surface  is  dirty  brown  in  color. 

Histological  Examination.  —  The  nodule  projecting  from  the 
uterine  canal  (Plate  XXI)  is  composed  of  non-striped  muscle  fibers.  Its  outer 
surface  is  in  places  covered  by  cylindrical  epithelium,  but  in  most  places  appar- 
ently by  several  layers  of  spindle-shaped  cells  like  connective  tissue.  Scattered 
everywhere  throughout  the  muscle  are  glandlike  spaces  varying  from  a  pin- 
point to  3  millimeters  in  diameter.  These  are  lined  by  one  layer  of  epithelium, 
which  in  the  smaller  glands  is  of  a  high  cylindrical  variety.  In  the  dilated 
glands,  however,  it  is  cuboidal,  or  has  become  almost  flat.  The  protoplasm  of 
the  cells  takes  the  hematoxylin  stain.  The  nuclei  are  oval  and  vesicular,  and  in 
many  places  it  is  possible  to  make  out  the  cilia.  The  glands  are  empty  or 
contain  a  granular  material  which  takes  the  hematoxylin  stain.  These  glands 
resemble  to  some  extent  those  of  the  cervix.  The  surface  of  the  mucosa  cover- 
ing the  anterior  uterine  wall  presents  in  places  a  wavy  outline  (Plate  XXII,  Fig. 


388  MYOMECTOMY — HYSTERO-MYOMECTOMY. 

1).  Its  epithelium  is  of  tlie  liigli  cylindrical  variety  and  is  everywhere  intact. 
In  a  few  places  it  is  swollen  and  somewhat  flattened.  The  glands  are  mod- 
erate in  number,  are  small  and  round  on  cross- sect  ion,  and  have  an  intact  epi- 
thelium. A  few  of  them  are  slightly  dilated  and  contain  desquamated  epithe- 
lium. The  glands  may  be  traced  from  7  to  10  millimeters  before  any  muscular 
substance  is  encountered  ;  they  then  end  abruptly  or  continue  into  the  muscle, 
where  they  can  in  places  be  traced  for  at  least  1  centimeter ;  this  downgrowth 
is  visible  in  many  places.  The  stroma  of  the  mucosa  is  composed  of  cells  whose 
nuclei  vary  from  oval  vesicular,  as  seen  near  the  surface,  to  deeply  staining  ones, 
as  noticed  in  the  depth  of  the  mucosa.  In  some  places  the  stroma  cells  have 
elongate  oval  nuclei,  and  it  is  impossible  to  distinguish  these  from  muscle  fibers. 
The  superficial  portions  of  the  stroma  show  marked  hemorrhage  which  is 
localized  to  certain  areas.  The  stroma  as  a  whole  does  not  appear  to  be  very 
vascular. 

The  thickened  and  striated  portion  of  the  anterior  uterine  wall  is  composed 
of  non-striped  muscle  fibers,  which  are  for  the  most  part  cut  longitudinally. 
The  fibers  run  in  all  directions,  are  closely  packed  together,  but  are  only  in  a 
few  places  concentrically  arranged.  Scattered  throughout  this  tissue  are  numer- 
ous cells  having  small,  round,  deeply  staining  nuclei  which  resemble  those  of 
lymphoid  cells.  Under  the  microscope  it  is  impossible  to  tell  where  the  coarsely 
thickened  zone  ends  and  the  normal  uterine  muscle  commences,  as  the  transition 
of  the  one  into  the  other  is  so  gradual.  Traversing  this  thickened  portion 
of  the  uterine  wall  are  small  clusters  of  glands,  precisely  similar  to  those  of  the 
uterine  mucosa  (Plate  XXII,  Figs.  1,  2).  These  glands  are  round  or  oval  and  are 
lined  by  one  layer  of  cylindrical  ciliated  epithehum.  A  few  longitudinal  sec- 
tions of  the  glands  are  here  and  there  visible.  Some  of  the  glands  are  dilated, 
one  of  them  reaching  5  millimeters  in  diameter.  The  epithelium  of  the  dilated 
glands  is  in  places  somewhat  flattened  or  has  entirely  disappeared. 

In  one  place  two  glands  are  seen  opening  into  a  dilated  gland.  Kearly  all 
of  the  glands  are  surrounded  by  stroma  similar  to  that  of  the  uterine  mucosa. 
A  small  isolated  gland  is  occasionally  found  lying  directly  between  the  muscle 
fibers,  and  a  few  of  the  cysts  have  no  stroma  surrounding  them.  The  gland 
invasioncan  be  traced  to  the  point  where  the  coarsely  stri- 
ated tissue  joins  the  uterine  muscle.  They  are  most  abundant 
near  the  uterine  mucosa,  and  gradually  diminish  as  one  passes  outward.  They 
may  be  scattered  anywhere  throughout  the  myomatous  growth,  but  appear  for 
the  most  part  to  occupy  the  spaces  between  the  muscle  bundles.  In  few  places 
can  any  concentric  arrangement  of  muscle  fibers  be  made  out  around  the  glands. 
The  glands  themselves  show  no  evidence  of  degeneration. 

From  this  description  it  will  be  seen  that  there  is  a  diffuse  muscle  thickening 
of  the  anterior  uterine  wall,  and  that  there  is  a  downgrowth  of  normal  uterine 
glands  into  the  newly  formed  muscle.  Along  the  lower  margin  of  the  growth 
is  a  typical  myomatous  nodule  5  millimeters  in  diameter. 

The  mucosa  covering  the  posterior  uterine  wall  is  normal. 

The  right  tube  and  ovary  are  normal. 


COMPLICATIONS    OF   HYSTEEO-MYOMECTOMY.  389 

Tlie  left  tube  is  normal.  The  small  cyst  of  the  left  ovary  lias  no  epithelial 
lining,  hence  its  exact  origin  can  not  be  ascertained. 

Complications   due   to   the   location   of    the   tumors. 

These  are,  perhaps,  the  most  important  of  all  complications  of  the  myoma- 
tous uterus.  According  to  the  location  of  the  tumors,  the  operation  is  easy  or 
difficult.  When  they  are  at  the  fnndal  end,  they  can  readily  be  lifted  out,  the 
broad  ligaments  exposed  and  cut  through,  when  the  cervix  forms  a  small  pedicle 
easily  dealt  with.  If,  however,  the  tumors  develop  underneath  the  movable 
pelvic  peritoneum,  the  effect  is  either  to  displace  the  bladder  or  the  rectum  and 
sigmoid  flexure,  to  open  out  the  broad  ligaments,  to  push  the  uterine  body  in 
the  opposite  direction,  or  to  raise  and  efface  the  cervix,  so  distorting  the  normal 
topographical  relations.  When  a  number  of  tumors  develop  in  this  way  under 
different  parts  of  the  pelvic  peritoneum  the  distortion  becomes  extreme  and  at 
ffrst  sight  all  landmarks  seem  obliterated.  It  is  just  these  cases  which  continue 
to  puzzle  even  experienced  gynecologists,  from  want  of  a  definite  routine  j)lan 
of  handling  them.  By  careful  attention  to  the  following  detailed  descriptions, 
however,  it  will  be  seen  that  even  the  most  complicated  and  distorted  myoma- 
tous uteri  may  be  treated  on  exactly  the  same  routine  plan  as  the  simpler 
forms. 

To  make  this  important  point  perfectly  clear  I  shall  first  consider  isolated 
tumors  in  each  of  the  important  situations,  and  then  state  what  changes  are 
produced  when  they  are  found  in  several  of  these  locations  at  once. 

2-t.  Elevation  of  Tubes  and  Ovaries  high  out  of  the 
Pelvis . — When  the  upper  part  of  the  body  of  the  uterus  is  involved  the 
tubes  and  ovaries  and  broad  ligaments  are  left  low  down  in  the  pelvis,  or  ele- 
vated only  slightly  above  the  brim,  and  apart  from  the  handling  of  the  large 
tumors  the  operation  is  not  much  different  from  the  supravaginal  extirpation 
of  a  normal  uterus. 

When  the  tumors  are  situated  in  the  body  of  the  uterus  below  the  fundus 
the  enlarging  mass  carries  the  lateral  structures  with  it  up  into  the  abdomen, 
and  the  broad  ligaments  acquire  a  vertical  instead  of  their  normal  horizontal 
direction.  Under  these  conditions  it  may  be  difiicult  to  get  at  them,  and  they 
at  first  appear  to  be  absent,  and  replaced  by  a  number  of  large  vessels  spread 
out  on  the  side  of  the  uterus.  A  closer  inspection,  however,  will  show  that 
these  vessels  come  together  at  the  pelvic  brim,  and  upon  drawing  the  uterus  to 
the  opposite  side  they  can  be  exposed,  picked  up  between  two  fingers,  ligated  in 
a  bunch  with  one  fine  ligature  on  the  pelvic  side,  and  tied  or  clamped  on  the 
uterine  side,  and  the  operation  begun  as  usual. 

If  the  sigmoid  flexure  is  raised  out  of  the  pelvis,  it  may  be  necessary  to 
split  the  meso-sigmoid  on  its  outer  side,  and  to  push  the  peritoneum  down  before 
the  vessels  can  be  exposed  and  tied.  Care  must  always  be  taken  in  tying  the 
vessels  above  the  brim  of  the  pelvis  not  to  include  a  ureter. 

25.  Globular  M  y  o  m  a  filling  the  Pelvis  . — The  spherical  myo- 
mata  form  a  distinct  group  which  recur  so  regularly  that  they  call  for  a  definite 
plan  of  dealing  with  them.  When  the  tumor  is  just  large  enough  to  fill  the 
67 


390 


MYOMECTOMY — H  YSTEEO-MYOMECTOMY. 


pelvis,  and  arises  from  the  lower  part  of  the  body  of  the  womb,  the  operator 
will  be  embarrassed  by  two  things.  In  the  first  place,  he  can  not  lift  the  tumor 
up  out  of  the  pelvis  and  through  the  incision,  and  so  deal  with  it  easily,  even  by 
grasping  it  with  stout  forceps  and  making  strong  traction ;  in  the  second  j)lace, 
he  finds  that  the  pelvis  is  so  choked  that  lie  can  not  get  room  enough  between 
the  tumor  and  the  pelvic  walls  to  tie  off  the  broad  ligaments,  and  particularly 
to  get  at  the  uterine  artery.  I  am  in  the  habit  of  meeting  this  difficulty  by 
catching  the  top  of  the  uterus  with  a  museau  forceps  or  a  stout  bullet  forceps 
on  the  left  side,  and  then  pulling  strongly  to  the  right,  and    rotating  the 


Fio.  508. — Pelvis  choked  by  a  Cup-and-ball   Myoma  (M)  compressing   Small   Intestines,  Bladder, 
Kectum,  Vermiform  Appendix,  and  Ureters.     See  Figs.  487  and  488. 

tumor  as  it  lies  in  the  pelvis  so  as  to  bring  the  top  of  the  broad  ligament  into 
view.  When  the  ligament  is  cut  tbrough,  by  rotating  still  farther  the  uterine 
artery  is  rolled  up,  exposed,  and  tied,  wdien  the  growth  can  be  lifted  out  of  the 
pelvis,  the  cervix  cut  across,  and  the  operation  completed  in  the  usual  way. 

26.  M y  o  m  a  t  a  wedged  in  the  Pelvis  . — Incarcerated  myomata 
form  a  peculiar  grou])  of  constant  recurrence.  On  opening  the  abdomen  the 
pelvis  is  found  choked  with  tumors,  the  landmarks  are  difficult  to  find,  and  the 
operator,  upon  seeing  the  immobility  of  the  mass,  anticipates  a  prolonged  and 
difficult  enucleation.  If,  however,  before  beginning  the  operation  he  has  taken 
note  of  the  vaginal  cervix  in  front  and  looks  close  enough  to  find  out  that  the 


Fig.  509. — Large  Myomatous  Uterus  filling  the  Lower  Two  Thirds  of  the  Abdomen. 

Showing  the  bladder  adherent  to  the  uterus  and  lifted  up  out  of  the  pelvis  with  it.  This  is  especially 
intended  to  show  the  difference  between  the  bladder  as  elevated  by  its  natural  anatomical  connections  and 
one  elevated  by  adventitious  peritoneal  adhesions.     Hystero-myomectoray.     Recovery.    Dec.  11,  1895. 


Fig.  510. — Displacement  of  the  Bladdek  due  to  a  Large  Myomatous  Uterus  with  the  Fundus  at  the 

Umbilicus. 

The  po.sition  of  the  bladder  is  indicated  by  enormous  tortuous  vessels  running  parallel  to  each  other  down 
toward  the  symphysis;  the  vessels  end  at  the  line  of  retlectiou  of  the  vesico-uterine  peritoneum.  Hystero- 
myomectomy.     liecovery.     Dec.  14,  1895.     y^  natural  size. 


COMPLICATIONS    OF    HYSTERO-MYOMECTOMY.  391 

main  masses  are  wedged  into  the  posterior  pelvis,  he  will  be  able  to  rectify  the 
chief  source  of  difficulty  by  instructing  an  assistant  to  push  upward  on  the 
tumor  with  two  fingers  in  the  vagina,  while  he  himself  makes  strong  traction 
from  above  with  museau  or  obstetric  forceps ;  as  the  tumor  is  disengaged  and 
extracted  from  its  bed  it  gives  forth  a  peculiar  loud  sucking  sound,  and  the 
whole  mass  rotates  on  its  transverse  axis  as  it  is  lifted  out  of  the  incision.  Such 
a  case  is  figured  in  the  text  (see  Figs.  487,  488,  and  508).  The  top  part  of  the 
mass  in  the  picture  is  the  part  which  lay  on  the  pelvic  floor  before  it  was  lifted 
out.  These  tumors  often  present  a  perfect  mold  of  the  posterior  part  of  the 
pelvis,  giving  an  exact  reproduction  of  the  form  of  the  sacrum.  All  the  myom- 
atous nodules  seen  on  section,  which  in  the  abdomen  would  liave  sprouted  out 
on  the  surface  of  the  mass  forming  numerous  bosses,  are  here  so  compressed 
by  the  hard  walls  of  the  pelvas  as  to  form  a  uniformly  rounded  surface. 

Quite  another  group  of  complications  are  introduced  when  the  tumors  arise 
low  down  on  the  uterine  body  or  in  the  cervical  region,  and  as  they  develop  lift 
up  the  loose  peritoneum  so  as  to  raise  the  pelvic  floor.  The  embarrassment 
here  lies  in  the  fact  that  at  first  sight  there  is  no  pedicle  in  view,  and  the  ques- 
tion how  to  make  one  is  difficult  for  a  novice  to  answer. 

Tumors  may  develop  in  this  way  in  front  of  the  uterus,  lifting  up  the  vesi- 
cal peritoneum  and  possibly  the  bladder  too,  or  behind  the  uterus,  lifting  up  the 
rectum,  or  on  either  broad  ligament.  They  may  also  grow  in  situations  between 
these  four  cardinal  points  or  in  several  of  these  positions  at  one  and  the  same 
time. 

As  these  are  the  cases  which  are  the  hardest  to  handle,  and  the  ones  which 
give  the  highest  mortality,  I  will  take  some  pains  to  dwell  on  the  treatment  of 
all  the  various  forms  in  detail,  and  first  I  will  speak  of 

27.  Myoma  below  the  Vesical  Peritoneum. — If  the  tumor 
grows  low  down  on  the  uterine  body  just  below  the  line  of  movable  peritoneum, 
it  may  then  continue  to  grow  out  into  the  cellular  space  between  the  vault  of  the 
bladder  and  this  line.  When  the  abdomen  is  opened  it  looks  as  if  the  bladder 
was  raised  high  up  on  the  anterior  face  of  the  uterus,  but  a  closer  inspection 
and  a  direct  palpation  show  that  the  lighter-colored  movable  peritoneum  has  no 
underlying  bladder,  but  that  the  bladder  is  really  still  down  in  the  pelvis  behind 
the  symphysis. 

In  other  cases,  the  usual  form,  the  bladder  itself  goes  up  into  the  abdomen 
with  the  developing  tumor  until  it  reaches  even  as  high  as  the  umbilicus.  These 
cases  must  be  distinguished  from  still  a  third  class,  where  the  bladder  has  simply 
formed  adhesions  across  the  top  of  the  uterus,  and  has  been  dragged  up  into  the 
abdomen  as  the  uterus  grew  in  size.  The  existence  of  such  adhesions  may  usu- 
ally be  detected  by  irregularities  or  breaks  in  the  line  of  attachment,  in  addition 
to  the  absence  of  the  movable  peritoneum  with  its  definite  line  of  attachment 
clearly  reflected  onto  the  uterus.  No  cases  are  so  liable  to  serious  injury  from 
the  very  outset  as  these,  for  when  the  bladder  is  displaced  high  up  in  the  abdo- 
men by  a  large  myoma  the  line  of  reflection  of  the  peritoneum  from  the  abdomi- 
nal wall  over  the  bladder  onto  the  utenis  is  also  often  raised  so  high  that  in 


392  MYOMECTOMY — 11 YSTERO-M  YOMECTOMY. 

cutting  in  as  usual,  unless  the  operator  bears  this  in  mind  and  makes  the  opening 
just  below  the  umbilicus,  he  is  liable  to  make  a  hole  in  the  bladder  before  he  knows 
it.  One  can  not  always  rely  on  the  sound  introduced  into  the  bladder  to  tell  just 
how  high  up  it  extends,  for  the  sound  may  be  stopped  by  the  tumor  and  not  go 
all  the  way  to  the  top  of  the  bladder.  The  bladder  may  also  lie  wholly  on  the 
anterior  face  of  the  tumor,  and  the  relations  of  the  peritoneum  to  the  anterior 
abdominal  wall  may  remain  undisturbed.  It  is  best,  therefore,  in  all  large 
myomata  to  open  the  peritoneum  at  first  high  up  and  then  to  enlarge  the  open- 
ing downward  (see  Figs.  509  and  510). 

After  opening  the  abdomen  the  chief  difficulty  in  handling  an  elevated  blad- 
der is  to  free  it,  so  as  to  be  able  to  get  at  the  cervical  part  of  the  tumor,  which 
necessarily  lies  behind  it.  This  is  best  done  by  first  tying  and  cutting  the  left 
ovarian  vessels  and  the  left  round  ligament.  The  operator  now  carefully  seeks 
out,  both  by  inspection  and  touch,  the  line  of  movable  peritoneum  crossing  the 
front  of  the  uterus,  tracing  it  all  the  way  from  one  round  ligament  to  the  other 
and  expecting  to  find  it  even  in  a  convex  line  extending  high  up  over  the  face 
of  a  large  tumor.  He  will  also  often  be  assisted  in  locating  this  line  by  the 
numerous  deeply  congested  sinuous  vessels  of  the  bladder  which  begin  suddenly 
just  under  the  reflected  peritoneum  and  run  in  a  parallel  course  down  toward 
the  brim  of  the  pelvis,  in  marked  contrast  to  the  flat  uterine  vessels  above  which 
have  no  such  definite  direction. 

The  incision  must  always  be  made  above  these  vesical  vessels  (see  Fig.  510), 
for  if  they  are  cut,  great  vascular  sinuses  are  opened  which  are  controlled  with 
difficulty  even  by  numerous  clamps.  If  the  peritoneal  cut  from  round  ligament 
to  round  ligament  is  carefully  made  just  at  the  line  of  reflection,  as  a  rule  no 
vessMs  are  severed  large  enough  to  need  a  clamp.  After  doing  this  the  operator 
tries  to  push  the  bladder  down  with  a  sponge.  If  it  sticks  he  may  try  a  little 
careful  dissection  with  a  spatula  or  knife  or  scissors,  keeping  in  the  cellular  tissue 
between  the  bladder  and  the  uterus.  The  sponge  ought  not  to  be  used  vigor- 
ously, for  I  have  seen  a  hole  4  centimeters  in  diameter  torn  in  the  bladder  in 
this  way.  But  the  bladder  usually  yields,  and  is  slowly  pushed  or  rubbed  down 
off  the  uterus.  If  the  left  ureter  is  lifted  high  out  of  the  pelvis,  this  goes  down 
too  with  the  bladder,  and  then  the  uterine  arteries  come  into  view  and  are  tied 
close  to  the  tumor  without  any  risk  of  including  the  ureter. 

In  one  of  my  cases  of  enormous  distorted  myomatous  uterus  I  did  not  ex- 
amine the  situation  minutely  enough,  and  thinking  I  was  following  the  reflected 
line,  I  cut  boldly  from  round  ligament  to  round  ligament.  There  was  at  once 
a  tremendous  hemorrhage  from  the  vesical  sinuses,  and  I  found  I  had  cut  off 
and  left  on  the  uterus  a  piece  of  the  bladder  as  large  as  the  palm  of  my  hand. 
The  wound  in  the  bladder  was  carefully  closed  with  fine  interrupted  silk  sutures 
down  to  the  mucosa,  and  the  patient  made  an  excellent  recovery. 

28.  Myoma  below  the  Posterior  Pelvic  Peritoneum . — A 
myoma  in  this  situation  is  rare,  for,  in  order  to  develop  under  the  perito- 
neum of  the  pelvic  floor  behind,  the  tumor  must  start  in  a  much  more  limited 
portion  of  the  cervix  than  myomata  starting  in  the  subvesical  space.     In  its  de- 


COMPLICATIONS    OF    HYSTEKO-MYOMECTOMY.  393 

velopment  a  tumor  in  this  situation  raises  the  peritoneum  posterior  to  the  uterus 
to  the  level  of  the  promontory  of  the  sacrum,  and  even  beyond  it,  obliterating 
Douglas's  cul-de-sac  and  raising  the  sigmoid  flexure  with  it.  In  such  cases,  on 
opening  the  abdomen  and  making  the  inspection  preliminary  to  enucleation,  the 
operator  finds  the  sigmoid  high  up  in  the  abdomen  spread  out  flat  on  the  surface 
of  the  tumor. 

The  commonest  way  in  which  this  condition  is  brought  about  is  by  a  tumor 
growing  not  exactly  from  the  posterior  median  part  of  the  cervix,  but  from  a 
point  higher  up  and  to  the  left.  Such  a  tumor,  as  it  develops,  lifts  uj)  the  pos- 
terior layer  of  the  left  broad  ligament,  the  peritoneum  of  the  pelvic  floor,  and 
the  sigmoid  flexure. 

It  is  most  important  to  know  just  how  to  handle  these  cases  to  avoid  injury 
to  the  sigmoid  and  the  rectum.  There  are  two  ways  of  dealing  with  this  com- 
plication— 

(1)  When  the  ovarian  vessels  which  run  under  the  sigmoid  are  so  concealed 
that  they  can  not  be  picked  up  and  tied,  so  that  the  operation  may  be  commenced 
in  the  usual  way,  they  can  be  reached  by  incising  the  peritoneum  reflected  from 
the  sigmoid  onto  the  tumor  on  its  outer  side  and  at  some  point  where  there  are 
no  vessels,  and  then  introducing  the  finger  into  the  loose  cellular  tissue  under- 
neath the  bowel  and  carefully  working  it  loose  and  pushing  it  down  otf  the  con- 
vexity of  the  tumor  until  the  ovarian  vessels  are  exposed. 

Sometimes  the  bowel  is  so  closely  attached  and  there  are  so  many  large  ves- 
sels in  the  way  that  it  is  not  safe  to  free  it  in  this  manner,  and  the  second  plan 
is  best. 

(2)  The  rectal  complication  is  for  the  time  neglected  and  the  ovarian  vessels 
sought  out  and  tied  by  pulling  the  mass  over  to  the  right  and  working  through 
the  pelvic  peritoneum  near  the  brim  of  the  pelvis,  or,  if  need  be,  by  raising  the 
ascending  colon  and  tying  them  beneath  it.  They  are  then  divided  and  the 
round  ligament,  which  can  always  be  found  near  the  internal  inguinal  ring,  often 
like  a  tense  bowstring,  is  next  tied  and  cut,  the  bladder  freed,  and  the  uterine 
vessels  tied  as  usual. 

The  next  step  deals  with  the  complications  by  cutting  across  the  cervical  part 
of  the  uterus  and  so  getting  at  the  posterior  myoma  from  in  front  and  below, 
where  it  lies  in  the  loose  cellular  tissue.  Its  enucleation  is  now  easily  effected 
by  rolling  it  up  and  out,  unwrapping  it,  as  it  were,  from  its  peritoneal  covering. 
After  doing  this  and  then  cutting  through  the  peritoneum  reflected  from  the 
bowel  onto  the  tumor,  it  may  be  from  beneath  instead  of  from  above,  the  rec- 
tum at  once  drops  into  its  noi-mal  position  in  the  pelvis.  The  operation  may 
then  l)e  completed  in  the  ordinary  way, 

29.  Myoma  in  the  Upper  Part  of  Broad   Ligament,  and 

30.  Myoma  in  the  Broad  Ligament  Proper. — When  the  tumor 
develops  on  either  side  of  the  uterus,  within  the  layers  of  the  broad  ligament,  as 
it  grows  it  separates  the  anterior  from  the  posterior  layer,  raises  them  up  into 
the  abdomen,  and  pushes  the  body  of  the  uterus  to  the  opposite  side.  The 
amount  of  disturbance  of  the  normal  topographical  relations  caused  by  such  a 


394 


MYOMECTOMY — HYSTERO-MYOMECTOMY. 


When  situated  nigh 


tumor  will  depend  upon  its  location  in  the  broad  ligament 

up,  the  only  effect  may  be  to  separate  widely  the  three  structures  which  lie 

close  together  at  the  coruu  uteri,  the  tube,  the  round  ligament,  and  the  ovary,, 


3    .    . 

O    CO  -^ 


COMPLICATIONS   OF    HYSTERO-MYOMECTOMY,  395 

which  are  then  found  si)read  apart  on  the  surface  of  the  tumor,  as  shown  in 
Fig.  511. 

When  the  tumor  grows  farther  down  in  the  broad  ligament,  in  addition  to 
parting  the  round  ligament  from  the  tube  and  the  ovary,  it  also  displaces  the 
ovarian  vessels  at  the  brim,  the  sigmoid  and  the  rectum,  and  the  uterine  vessels 
and  often  also  the  bladder.  This  complication  will  be  recognized  by  the  dis- 
placement of  these  structures. 

The  treatment  of  such  a  mass  on  the  left  side  is  to  begin  the  enucleation  by 
freeing  the  sigmoid  enough  to  get  at  and  tie  and  sever  the  ovarian  vessels,  and 
then  to  tie  and  cut  the  round  hgament,  and  to  connect  these  two  incisions  by 
just  cutting  through  the  peritoneum,  which  is  pushed  down  toward  the  pelvic 
brim.  On  grasping  the  tumor  and  pulling  it  to  the  right  it  is  stripped  out  of 
its  cellular  bed  and  the  uterine  vessels  brought  into  view  in  the  angle  in  front, 
between  the  tumor  and  the  body  of  the  uterus,  where  they  are  tied  low  down 
and  the  cervix  cut  across  and  the  operation  finished  as  usual. 

Too  great  care  can  not  be  taken  in  these  cases  to  avoid  the  ureter,  which 
may  sometimes  be  found  lifted  up  into  the  abdomen  over  the  convexity  of  the 
tumor.  This  is  done  by  making  the  incision  between  the  ovarian  vessels  and 
the  uterine  end  of  the  round  ligament  and  pushing  down  the  peritoneum  as 
stated.  If  the  ureter  is  displaced,  it  goes  down  into  the  pelvis  with  the  perito- 
neal covering  of  the  tumor  and  is  not  touched  at  all.  Intraligamentary  myomata 
on  the  right  side  require  a  different  sort  of  treatment.  Here  the  left  broad  liga- 
ment is  opened,  the  bladder  fi-eed,  and  the  uterine  vessels  tied  as  described  in 
the  typical  operation ;  then  the  cervix  is  cut  across  and  the  uterine  vessels  on  the 
right  side  are  easily  found  in  the  cellular  tissue  and  caught  by  the  side  of  the 
cervix. 

The  intraligamentary  mass  is  now  easily  shelled  out  by  running  the  fingers 
into  the  loose  tissue  beneath  it,  grasping  and  rolling  it  up  and  out,  unfolding  it 
from  its  peritoneal  investment,  and  bringing  the  broad  ligament,  and  lastly  the 
ovarian  vessels,  into  view.  These  are  clamped,  and  the  enucleation,  which  at 
first  sight  looked  difficult,  is  completed  in  less  than  a  minute. 

31.  Myoma  situated  Anter  o-l  aterally,  twisting  the  Uterus. 
— I  have  seen  one  case  in  which  a  large  myoma  had  developed  under  the  pelvic 
peritoneum  in  the  angle  between  the  bladder  and  the  left  broad  ligament.  As 
the  tumor  grew  and  came  to  occupy  a  more  central  position,  the  uterus  was 
raised  high  out  of  the  pelvis  and  rotated  at  the  same  time  with  the  bladder 
attached  to  it;  so  twisting  the  bladder.  After  freeing  the  ovarian  vessels  and 
the  round  ligaments  I  found  I  could  not  detach  the  bladder  and  push  it  down, 
even  with  the  most  careful  dissection,  without  tearing  its  structure,  so  I  aban- 
doned the  effort  in  this  direction  and  furthzsr  opened  up  the  broad  ligament  on 
the  left  side,  until  the  uterine  vessels  low  down  were  exposed.  I  then  worked 
the  finger  out  into  the  loose  cellular  tissue  in  the  angle  between  the  vagina, 
supravaginal  cervix,  and  the  bladder,  and  freed  the  bladder  first  at  this  point, 
and  then  continued  to  strip  it  loose  from  its  attachments  from  below  up- 
ward, reversing  the  ordinary  procedure ;  the  rest  of  the  enucleation  was  then 


396 


MYOMECTOMY — HYSTERO-MYOMECTOMY. 


easily  completed.     Care  must  be  taken  in  following  this  method  to  keep  close 
to  the  uterus  so  as  to  avoid  the  ureter. 

32.  Myoma  situated  Postero-laterally . — The  special  point  to 
be  noted  in  myomata  developing  postero-laterally  is  the  tendency  to  elevate 
the  rectum  and  sigmoid  flexure  when  the  tumor  is  located  on  the  left  side. 
This  complication  will  be  treated  by  dissecting  off  the  bowel  and  ligating  the 
ovarian  vessels  of  that  side  as  already  described  above. 


Fig.  512. — Myomatous  Uterus  weighing  89  Pounds,  seen  from  Behind. 

Showing  the  e.xtreme  distortion  of  the  uterine  body  by  the  tumors  occupying  every  conceivable  position. 
The  point  of  amputation  of  the  cervix  is  shown  at  C,  and  the  right  and  left  "ovaries  and  tubes  are  seen  above 
on  either  side.  The  left  tube  is  lengthened  out  and  displaced  by  a  large  intraligamentary  mass.  The  lower 
part  of  the  tumor,  from  a  point  above  the  cervix  transversely  across  to  the  riirht,  was  entirely  subperitoneal. 
Hystero-myoinectomy.     Kecovery.     Longest  diameter  39  centimeters.     San.  March  16,  1895.  '  3^  natural  size. 

33.  Myomata  situated  under  the  Pelvic  Peritoneum  in 
Several  of  these  Positions  at  Once . — I  have  enumerated  above 
(Nos.  28-32)  the  various  positions  in  which  myomata  may  be  found  singly  be- 
neath the  pelvic  peritoneum,  and  dwelt  carefully  on  the  special  character  of  the 
displacements  produced  and  their  proper  management  at  the  operation ;  I  now 
wish  to  speak  of  a  still  more  complicated  class  of  cases  in  which  the  tumors  de- 
velop in  two  or  more  of  these  situations  at  once. 

In  addition  to  the  subperitoneal  myomata,  large  tumors  often  spring  from  the 
body  of  the  uterus  above  the  pelvic  peritoneum,  producing  an  irregular  com- 
plicated mass  of  grcAvths  iirojecting  free  into  the  abdominal  cavity,  as  well  as 
distorting  the  normal  relations  of  the  pelvic  organs  to  the  utmost  possible  de- 


COMPLICATIOXS    OF    HTSTERO-M YOMECTOMY. 


397 


gree.  These  growths  afford  us  some  of  the  largest  as  well  as  the  most  ditficult 
tumors  to  handle.     (See  Fig.  512.) 

1  should  note  here  the  fact  that  the  displacement  of  the  entire  pelvic  floor 
may  also  be  produced  by  a  single  tumor  starting  at  any  point  in  the  cervical 
region,  and  attaining  a  size  sufficient  to  lift  the  body  of  the  uterus  high  up  into 
the  abdomen. 

Where  the  whole  pelvic  floor  is  raised  in  this  way,  the  ojDerator,  on  opening 
the  abdomen,  is  apt  to  flnd  the  peritoneum  reflected  from  the  anterior  abdom- 
inal wall  over  onto  the  uterus  a  short  distance  below  the  umbilicus ;  at  the  sides 
no  broad  ligaments  are  found,  but  groups  of  large  ovarian  vessels  course  down 
over  the  sides  of  the  tumors  and  disappear  below  the  abdominal  peritoneum ; 
one  often  sees  also  enormous  lymph  channels  in  the  same  situation,  sometimes 
holding  as  much  as  a  pint  of  serum  ;  posteriorly  the  sigmoid  is  raised  high  up, 


SigttLflex 


rund.itt. 


Top  of  Bladd. 


Cervix. 
Penton. 


Fig.  513.— Complicated  n\»ii.i4v,-Miiv,Mtcioiii  sidwinc  Lxtensue  "slbpekitoneal  Development. 

The  cervix  is  raised  high  out  of  the  pelvis,  and  the  bladder  ha.s  been  forced  up  into  the  abdomen.  _  The 
fundus  uteri  lies  liigh  above  the  umbilicus  opposite  the  displaced  sigmoid  fle.xure.  The  line  of  reflection  of 
the  peritoneum  over  the  side  of  the  tumor  is  shown.     Hystero-myomectomy.     Kceovery.     Feb.  9,  189.5. 


even  above  the  umbilicus.  The  whole  large  mass  presents  at  flrst  sight  an  ap- 
pearance well  calculated  to  make  the  boldest  operator  hesitate  before  attacking 
it,  for  the  part  of  the  uterus  covered  with  the  tirinly  attached  peritoneum  is 
often  not  larger  than  the  palm  of  the  hand,  while  this  area  is  surrounded  on 


398  MYOMECTOMY — HYSTERO-MYOMECTOMY. 

all  sides  bj  the  movable  peritoneum  covering  a  great  tumor  mass,  and  the  hard 
question  is,  how  to  commence  the  operation  of  removing  the  growths  without 
cutting  large  vessels  and  sacrificing  considerable  portions  of  the  displaced  peri- 
toneum. 

These  difliculties  may  all  be  met  by  applying  the  principles  developed  in  the 
previous  sections  of  this  chapter.  The  sigmoid  flexure  may  often  be  let  down 
behind  by  incising  its  peritoneum,  anteriorly  or  laterally,  but  never  on  the 
median  side,  at  the  point  of  reflection ;  then  the  ovarian  vessels  are  carefully 
souo-ht  out  and  caught  in  a  bunch  and  tied  at  a  point  well  above  the  pelvic  brim ; 
next,  the  round  ligament  is  found  and  traced  up  to  its  uterine  attachment  and 
tied  ;  then,  continuing  the  enucleation,  the  top  of  the  left  broad  ligament  is 
opened,  the  vesico- uterine  fold  of  peritoneum  is  cut  through  from  round  liga- 
ment to  round  ligament,  and  the  bladder  pushed  and  dissected  down ;  then  the 
tumor  in  the  left  broad  ligament  is  drawn  up  and  to  the  right  until  the  uterine 
vessels  are  exposed  and  tied  and  the  cervix,  which  is  known  by  its  attachment  to 
the  vagina,  is  cut  across ;  last,  the  right  uterine  artery  is  found  and  tied,  and  the 
large  posterior  and  the  right  broad  ligament  masses  turned  out  of  their  cellular 
bed  by  catching  them  below  and  rolling  them  up  and  out,  so  that  the  right 
round  ligament  comes  into  view.  When  this  and  the  right  ovarian  vessel  are 
clamped  the  enucleation  is  complete. 

34.  Myomata  displacing  the  Ureters  Upward. — Among  the 
large  myomata  described  in  the  last  section  I  have  had  a  number  of  cases  of  ex- 
treme displacement  of  one  or  both  ureters.  In  order  to  bring  this  about  the 
tumor  nmst  naturally  start  to  grow  at  some  part  of  the  lower  uterine  segment 
and  then  develop  below  the  level  of  the  ureter. 

The  displaced  ureter  looks  like  a  large  vein  or  a  round  ligament.  It  is  often 
dilated  to  1  or  2  centimeters  in  diameter  (hydroureter) ;  it  is  flattened  and  whit- 
ish in  color.  It  would  seem  easy  at  first  sight  to  distinguish  this  organ  from 
other  broad -ligament  structures  by  a  simple  inspection  and  by  following  its 
course,  but  such  is  not  the  case.  I  have  several  times  been  greatly  confused  in 
determining  what  structure  I  had  in  hand.  Once,  after  a  painstaking  examina- 
tion, I  concluded  I  was  dealing  with  a  large  vein  on  the  right  side ;  I  tied  it  in 
two  places  and  cut  between,  and  then,  on  passing  in  a  sound,  found  I  had  cut 
the  ureter. 

After  completing  the  enucleation  of  the  uterus  and  tumors  I  made  good  my 
error  by  anastomosing  the  upper  end  of  the  severed  ureter  into  the  side  of  the 
lower  end  (uretero-ureterostomy),  and  the  patient  recovered. 

Another  time  I  discovered  that  I  had  tied  a  ureter  by  cutting  a  longitudinal 
slit  in  it  (ureterotomy)  and  running  in  a  sound.  It  was  stopped  by  the  ligature, 
which  I  at  once  took  off,  and  no  harm  resulted. 

I  show  in  Fig.  513  a  diagram  of  a  myomatous  utenis  weighing  23^  pounds, 
where  both  ureters  were  lifted  high  up  and  out  of  the  pelvis ;  the  right  ureter 
was  kinked  in  two  places  and  raised  6  centimeters  above  the  brim,  while  the  left 
ureter  was  arched  high  up  to  a  point  10  centimeters  above  the  pelvic  brim.  The 
cardinal  principle  in  treating  this  complication  is  to  keep  as  close  as  possible  to 


COMPLICATIOXS    OF   HYSTERO-MYOMECTOMT. 


399 


the  uterus  throughout  the  enucleation ;  this  is  done,  after  tying  the  left  ovarian 
vessels  and  left  round  ligament  and  freeing  the  vesical  peritoneum,  by  pushing 
down  the  peritoneum  on  the  left  side  and  picking  up  the  uterine  vessels  close  to 
the  tumor,  or  by  catching  the  artery  by  itseK  in  the  cellular  tissue ;  in  this  way 


Fund  lit. 


Top  of  Uadd 


Opening  of  ureter 
Cervix 


Fig.  514. — Complicated  Hystero-myomectomy. 


The  pelvic  peritoueum  is  displaced  high  up  into  the  abdomen  by  the  enormous  myomatous  uterus,  as 
indicatecl  by  the  line  bcginnincr  above  the  bladder  and  extending  up  to  the  round  ligament,  the  oviduct,  and 
ending  above  the  sacral  promontory.  The  fundus  lies  above  and  on  top  of  the  uterus;  above  the  und)ilicus 
lies  the  sigmoid  flexure,  seen  in  cross  section.  The  bladder  lies  wliolly  in  the  abdomen,  and  both  ureters 
are  displaced  above  the  pelvic  brim  :  the  left  is  indicated  in  dotted  outline.  Tlie  jjclvis  is  also  choked  by  the 
tumor,  and  the  cervix  lies  near  the  level  of  the  superior  strait  behind  the  symphysis.  Hystero-myomectomy. 
Keoovery. 

the  ureter  goes  down  at  the  side  and  drops  into  its  normal  place.  The  right 
ureter  is  in  less  danger,  as  in  rolling  the  tumors  up  and  out  it  is  simply  peeled 
off,  and  remains  behind  with  the  peritoneum  which  had  covered  the  tumor.  In 
this  way  the  complication  is  avoided,  and  the  operator  does  not  even  need  to  be 
aware  of  the  displacement  on  the  right  side. 

Should  a  ureter  be  incised  it  may  be  sutured,  as  described  in  Chap.  XIII. 

If  a  ureter  is  severed,  leaving  an  end  sufficiently  long  below,  the  best  plan 
will  be  to  anastomose  it  (see  Figs.  262  and  203,  Yol.  I,  Chap.  XIII,  pp.  406 
and  407). 

If  it  is  cut  too  near  the  bladder  to  be  anastomosed  into  itself,  the  upper  end 
should  be  turned  into  the  bladder  (uretero-cystostomy,  see  Fig.  260,  Vol.  I,  Chap. 
XIII,  p.  400). 


400  MYOMECTOMY — H  YSTERO-MYOMECTOMY. 

If  the  ureter  is  tied  in  a  mass  of  tissue  with  tlie  uterine  vessels,  it  will  usually 
do  to  cut  the  ligature  and  retie  the  vessels  and  let  the  ureter  alone ;  but  if  there 
is  doubt  as  to  the  integrity  of  its  inner  coats,  it  will  be  best  to  put  a  flexible  ure- 
teral catheter  in  through  the  Ijladder,  reaching  well  up  above  the  point  of  in- 
jury, and  to  leave  it  there  for  two  or  three  days. 

Complications  due  to  pregnancy,  ascites,  and  other  causes. 

35.  Myoma  with  Pregnancy . — The  relations  of  myomata  to  preg- 
nancy is  a  question  of  great  practical  importance,  and  the  surgeon  is  often  called 
upon  to  decide  the  following  questions : 

(a)  Whether  pregnancy  can  occur  in  a  given  case. 

(b)  When  pregnancy  exists,  whether  the  life  of  the  mother  is  in  danger. 

(c)  Whether  a  living  child  can  be  carried  and  born  at  term. 

It  is  unusual  for  a  woman  with  a  myomatous  uterus  of  large  size  to  become 
pregnant,  and  where  there  are  a  number  of  myomatous  masses  the  patient  is  apt 
to  abort  in  from  two  to  four  months.  Many  eases,  however,  have  occurred  in 
which  the  uterus  has  carried  its  additional  burden  to  full  or  nearly  to  full  term, 
and  a  viable  child  has  been  born.  One  of  my  patients  with  myomata  even  be- 
came pregnant  after  fifteen  years  of  married  life. 

The  pratice  is  in  general  to  a  too  frequent  interference  with  the  pregnancy, 
and  in  many  of  the  instances  of  hystero-myomectomy  during  pregnancy  which 
are  reported  and  figure  in  the  journals,  if  the  patient  had  been  let  alone  she 
would  have  gone  on  and  produced  a  living  child. 

The  question  as  to  the  risk  in  letting  the  pregnancy  go  on  to  term  is  to  be 
settled  by  the  size  and  position  of  the  tumors.  Small  tumors  of  the  upper  part 
of  the  uterus  do  not  impede  the  birth  ;  but  when  they  are  attached  to  the  cer- 
vical region  the  important  question  is  whether  the  tumor  is  large  enough  to  in- 
terfere with  the  passage  of  the  head,  and  if  it  is,  whether  it  can  be  pushed  up 
from  the  pelvis  out  of  the  way  when  labor  begins. 

If  the  tumor  is  estimated  as  too  large  to  let  the  head  go  by,  the  surgeon  may 
then  consider  whether  or  not  he  will  be  able  to  enucleate  it^er  vaginam  several 
months  before  the  labor. 

The  child  should  have  the  benefit  of  a  doubt,  for  after  labor  begins  it  may 
still  be  saved  by  turning,  by  the  use  of  the  forceps,  or  by  a  Porro  operation. 
If  the  child  has  died,  it  may  be  taken  away  by  craniotomy. 

An  extra-uterine  pregnancy  may  also  exist  as  a  complication  in  a  fibroid 
uterus. 

36.  Myoma  simulating  Pregnancy. — I  had  a  case  (Y.  W.,  3198, 
Nov.  28,  1894)  of  fibroids  which,  in  size  and  disposition  of  the  tumors,  simulated 
an  advanced  abdominal  pregnancy  (see  Fig.  515).  The  entire  mass  was  28  cen- 
timeters (11  inches)  long,  and  lay  transversely  in  the  abdominal  cavity.  In  the 
left  iliac  fossa  there  was  a  round  tumor  the  size  of  the  head,  and  a  constriction 
behind  it  represented  the  neck.  The  body  of  the  uterus  occujjied  the  position 
of  shoulders,  and  at  the  cornu,  which  was  turned  toward  the  anterior  abdominal 
wall,  was  a  peculiar  conical  fil)roid  excrescence  like  the  stump  of  an  arm.  Be- 
hind the  uterus,  and  lying  in  the  right  abdomen,  a  cylindrical  mass  bellied  out 


COMPLICATIONS    OF    HYSTERO-MYOMECTOMT. 


below,  and  imitated  the  size  and  shape  of  the  normal  fetal  abdomen, 
feature  wanting  was  an  attempt  to  reproduce  the  lower  limbs. 


401 
The  only 


Fig.  515. — MTOMATors  Uterus  presentixg  an  Extraordinary  Mimicry  of  a  Child  in  a  Transverse 

Position. 

Seen  from  the  front.  The  supposed  head  lay  on  the  left  side  behind  the  left  broad  ligament  with  a  well- 
defined  neck  back  of  the  uterus.  A  curious  conical  nodule  extending  out  under  the  right  uterine  tube  felt 
like  the  arm  of  the  child,  while  the  large  mass  occupying  the  ^-ight  iliac  fossa,  and  seen  behind  the  right 
broad  ligament,  had  the  form  of  the  body  from  the  shoulders  down.  The  longest  diameter  was  28  centi- 
meters.    Path.  No.  533.     Nov.  28, 1894.     Hystero-myomectomy.     ^|^  natural  size. 


Felt  through  the  abdominal  walls,  the  imitation  of  a  dead  fetus  at  term 
was  exact,  and  a  differential  diagnosis  was  only  made  by  the  most  careful  palpa- 
tion, recognizing  the  hardness  of  the  masses  and  their  close  attachment  to  the 
posterior  surface  of  the  uterus,  which  could  be  outlined  under  anaesthesia.  The 
history  showed  also  that  they  had  existed  for  some  years. 

37.  Myoma  and  Ascites,  Feeble  Heart,  Xephritis,  etc. — 
Ascites  is  a  complication  by  no  means  rare  if  we  take  into  consideration  lesser  as 
well  as  larger  quantities  of  ascites.  We  seldom,  however,  find  as  much  as  1  or  2 
hters  of  serum  in  the  abdomen.  The  cause  of  the  ascites  is  not  known.  One 
of  the  most  striking  cases  of  this  kind  I  have  ever  seen  was  that  of  a  woman 
from  which  I  removed  Y  liters  of  fluid.  The  patient  was  thirty-two  years  old, 
and  had  had  two  children,  the  youngest  five  years  old  ;  soon  after  the  birth  of 
this  child  she  noticed  a  lump  in  the  lower  abdomen,  which  remained  stationary 
for  over  three  years,  when,  without  apparent  cause,  the  abdomen  began  to  en- 
large. At  the  time  of  her  admission  into  the  hospital  the  abdominal  enlarge- 
ment was  uniform,  fluctuating,  and  not  tense  or  tender  at  any  point.  The  um- 
bilical circumference  was  87|^  centimeters,  and  halfway  above  the  umbilicus  it 
was  83  centimeters  (see  Fig.  4HC). 

Per  vaginam,  the  cervix  was  found  to  be  jammed  down  on  the  pelvic  floor 
by  hard  uterine  tumors  filling  the  pelvis.  In  the  left  vault  a  strong  thrill  was 
felt  with  each  pulsation  of  the  uterine  artery,  (trowing  from  the  upper  part  of 
the  pelvic  mass  of  tumors  were  two  fibroid  balls  about  as  large  as  a  fetal  head  at 


402  MYOMECTOMY — HYSTEKO-MYOMECTOMY. 

the  seventh  month,  9  X  0  X  ^  centimeters,  attached  bj  pedicles  respectively  1 
and  1|-  centimeter  long  and  2x3  and  2^  X  2|  centimeters  in  thickness. 

The  left  mass  received  three  large  omental  vessels,  which  appeared  to  plunge 
directly  into  its  substance. 

Between  these  short  pedicled  tumors  and  the  anterior  abdominal  wall  there 
was  a  layer  of  ascitic  fluid.  On  striking  the  tumor  on  the  left  a  sharp  blow  at 
a  point  5  centimeters  above  the  symphysis,  it  yielded  at  once  and  returned  in 
one  or  two  seconds,  hitting  the  fingers  a  decided  blow,  and  this  phenomenon 
could  be  felt  over  an  area  about  5  centimeters  in  diameter.  The  impulse  of  the 
blow  could  also  be  seen  on  the  abdominal  wall  on  pushing  back  the  tumor  and 
taking  the  hand  away,  thus  perfectly  reproducing  ballottement,  the  diagnostic 
sign  of  pregnancy.  On  giving  the  mass  in  the  pelvis  a  decided  upward  blow 
by  the  vaginal  finger,  a  distinct  gentle  wave  could  be  seen  traveling  from  the 
symphysis  up  the  abdominal  wall. 

In  excessive  anemia  the  best  time  to  operate  is  just  before  an  ex- 
pected period,  when  a  maximum  improvement  has  taken  place.  In  cases  of 
heart  disease,  nephritis,  or  other  organic  lesion,  the  determination 
whether  or  not  an  operation  is  advisable  will  depend,  in  the  first  place,  upon  the 
relationship  believed  to  exist  between  the  tumor  and  the  visceral  lesion.  If  the 
tumor  aggravates  the  organic  affection  or  stands  in  causal  relation  to  it,  the 
operator  will  be  justified  in  taking  risks  he  would  not  otherwise  assume,  with 
the  hope  of  either  ameliorating  the  condition  or  at  least  of  checking  the  advance 
of  the  disease.  A  marked  improvement  is  often  especially  noticeable  in  cases 
which  may  be  supposed  from  the  urinary  analysis  to  be  in  the  earlier  stages  of 
nephritis.  A  pyelonephrosis  may  be  treated  by  incision  and  drainage, 
and  then  the  myoma  may  be  removed.  The  operation  is  especially  urgent  in 
these  cases,  as  there  is  apt  to  be  a  hydroureter  on  the  opposite  side.  "With  the 
relief  of  the  pressure  the  normal  function  of  a  non-infected  kidney  may  be 
speedily  restored. 


CHAPTER   XXXII. 

OPERATIONS   DURING   PREGNANCY. 

1.  Brief  historical  sketch. 

2.  Pre-existing  pelvic  conditions  often  made  manifest  by  pregnancy. 

3.  Principles  of  operation  during  pregnancy. 

4.  Indications  for  operation :   (1)   Incarcerated   uterus.      (2)  Ovarian,  parovarian,  and   dermoid 

cysts,  and  solid  tumors  of  the  ovary.  (3)  Uterine  myoma :  (a)  Rules  as  to  surgical  inter- 
ference, (b)  Operation.  (4)  Cancer  of  the  cervix.  (5)  Pyosalpinx  and  ovarian  abscess.  (6) 
Appendicitis. 

Pregnancy  does  not  constitute  a  contra-indication  to  the  performance  of 
any  necessary  gynecological  abdominal  operation  upon  the  uterus,  tubes,  or  ova- 
ries. The  danger  to  the  life  of  the  mother  is  not  materially  increased  by  the 
fact  that  she  is  pregnant,  and  abortion  does  not  occur  as  a  rule  when  the  opera- 
tion does  not  affect  the  uterus  itself. 

This  radical  reversal  of  the  opinions  of  our  predecessors,  who  considered 
all  operations  especially  dangerous  in  the  pregnant  state,  has  been  brought  about 
by  the  advances  in  surgical  technique  in  general,  and  in  particular  by  the  prac- 
tical disappearance  of  sepsis  and  fever  during  the  recovery  from  operations  (see 
M.  Punge,  TJntersuchungen  uber  den  Einfluss  der  gesteigerten  midterlicTien  Tem- 
peratur  in  der  Schtoangerschaft  auf  das  Lebea  der  Friicht.  Arch.  f.  Gyn., 
1877,  vol.  xii,  p.  16). 

This  important  surgical  advance  was  first  signalized  by  Dr.  M.  D.  Mann,  of 
Buffalo,  in  an  elaborate  paper  published  in  the  Trans,  of  the  Amer.  Gyn.  Soc, 
1883. 

The  next  work  of  importance  was  that  of  Dr.  E.  Thoman,  Schwangerschaft 
und  Trauma.  Zur  Frage  uber  die  Zuldssiglieit  chirurgischer  Eingriffe  bei 
Schwangeren.,  "Wien,  1889. 

Dr.  Mann  was  able  to  show  that  out  of  eighty-three  gynecological  opera- 
tions of  all  sorts  (not  abdominal)  only  sixteen  were  followed  by  abortion ; 
and  but  three  mothers  died. 

Thoman  shows  that  Nature  herself  first  pointed  the  way  by  the  frequent 
uncompUcated  recoveries  of  pregnant  women  from  various  accidental  injuries ; 
he  then  proves,  by  sifting  all  the  reported  cases  out  of  the  surgical  literature, 
that  operations  of  all  sorts  may  be  safely  undertaken,  that  operations  upon  the 
external  genitals  and  vagina  are  permissible,  and  that  even  up  to  the  date  of  his 
publication  various  abdominal  operations  had  been  performed.  I  have  quoted 
these  two  papers  because  of  their  historical  importance ;  the  more  recent  statis- 
tics are  still  more  favorable. 

68  403 


40i  OPERATIOXS    DURIXG    PREGJSTAXCY. 

In  this  connection,  too,  an  important  lesson  as  to  the  tolerance  of  the  preg- 
nant uterus  may  be  learned  from  the  cases  of  cattle  horn-rip  of  the  abdominal 
wall,  in  which  protruded  intestines  were  cleansed  and  returned  and  the  abdo- 
men closed  without  interrupting  the  pregnancy.  (See  Dr.  R.  P.  Harris,  Amer. 
Jour,  of  Ohst,  July,  1887,  page  682  et  seq.). 

Ovarian  and  uterine  tumors  are  often  noticed  for  the 
first  time  during  pregnancy,  not  so  nmch  because  they  have  been 
stimulated  and  developed  by  the  physiological  changes  in  the  pelvic  circulation 
as  on  account  of  the  encroachment  of  the  growing  uterus,  first  on  the  pelvis, 
and  next  on  the  supplementary  space  of  the  abdominal  cavity.  A  tumor  which 
may  have  long  been  concealed  in  a  spacious  cavity  now  becomes  prominent, 
either  from  being  hfted  out  of  the  pelvis  within  easy  touch  through  the  abdomi- 
nal walls,  or  because  there  is  no  longer  room  enough  in  the  pelvis  or  abdomen  to 
harbor  both  the  tumor  and  the  pregnant  uterus.  The  most  marked  evidence  of 
rapid  growth  is  found  in  the  case  of  malignant  tumors,  which  may  even  appear 
to  grow  as  fast  as  the  uterus  itself. 

It  has  been  noted  in  the  case  of  some  fibroid  tumors  that  they  may  increase 
rapidly  in  size  or  become  edematous  during  pregnancy. 

Other  pelvic  conditions,  such  as  adhesions  of  the  uterus,  ovaries 
and  tubes,  and  pelvic  abscesses,  also  often  become  evident 
during  pregnancy,  owing  to  the  changes  which  occur  in  the  size  and 
position  of  the  uterus,  producing  traction  on  adhesions,  and  rupturing  an  ab- 
scess ;  or  the  confined  uterus,  unable  to  escape  into  the  abdomen,  may  make  dan- 
gerous pressure  on  the  bladder  and  rectum. 

J.  Murphy  {Lancet,  1895,  vol,  i,  p.  118)  even  had  to  operate  on  a  pregnant 
woman  on  account  of  collapse  due  to  hemorrhage  produced  by  the  rupture  of 
an  ovarian  adhesion  bringing  about  a  rare  form  of  hematocele ;  about  twenty 
ounces  of  blood  were  removed  from  the  abdomen  and  the  bleeding  from  a  torn 
adhesion  to  the  right  ovary  checked. 

The  torsion  of  the  pedicle  of  an  ovarian  cyst,  with  its  ac- 
companying symptoms — pain,  peritonitis,  or  collapse — occurs  with  nmch  greater 
frequency  during  pregnancy,  and  may  be  the  first  indication  of  the  existence 
of  a  tumor. 

Sometimes  even  large  ovarian  tumors  escape  observation  in  a  most  surprising 
way  throughout  the  entire  pregnancy,  and  are  only  discovered  when  the  uterus 
is  empty  and  the  abdomen  remains  enlarged  ;  palpation  of  the  entire  abdominal 
cavity  is  easily  practiced  early  in  the  puerperium  through  the  flaccid  abdominal 
walls,  and  a  tumor  easily  discovered  and  handled  which  was  previously  inacces- 
sible. 

Although,  as  I  have  stated,  necessary  operations  may  be  safely  per- 
formed during  pregnancy,  no  cautious  surgeon  would  elect  the  pregnant  state 
in  which  to  operate,  for  the  risks  of  abortion,  the  increased  difficulties  pro- 
duced by  the  presence  of  an  enlarged  uterus,  and  the  great  vascularity  of 
the  parts,  must  always  weigh  against  doing  the  operation  if  it  can  be  safely 
postponed. 


INDICATIONS    FOR    OPERATION.  405 

It  must  also  always  be  remembered  that  there  are  two 
lives  to  be  considered,  and  the  surgeon  must  strain  ev^ery  effort  toward 
saving  both  of  them  when  possible.  If  one  must  be  sacrificed,  the  mother,  with 
her  duties  and  her  established  interests  in  life,  must  be  saved ;  fortunately,  how- 
ever, such  an  alternative  can  not  often  arise,  for  the  disease  which  threatens  to 
take  the  mother's  life  mil  also  take  the  child's  along  with  it ;  for  example,  a 
large  ovarian  tumor  producing  extreme  dyspnea  if  not  relieved  will  destroy  both 
mother  and  child. 

The  conservative  surgeon  will  ever  bear  in  mind  the  two  categories  under 
the  one  or  the  other  of  which  all  of  these  cases  may  be  classified : 

First,  those  in  which  the  operation  is  absolutely  neces- 
sary to  save  the  mother's  life  (indicatio  vitalis). 

Second,  those  in  which  the  operation  is  elective. 

In  the  interests  of  the  child,  small,  non-adherent  ovarian  tumors  seen  late  in 
pregnancy,  which  can  be  watched,  aud  most  fibroids  of  the  body  of  the  uterus, 
should  not  be  interfered  with. 

The  following  principles  apply  alike  to  all  operations  during  pregnancy : 

1.  The  best  time  to  operate  in  the  interest  of  both  mother  and  child  is  in  the 
early  months. 

2.  The  thorough  vaginal  scrubbing  and  disinfection  usual  in  the  preparation 
for  other  abdominal  operations  may  be  omitted. 

3.  Take  care  on  opening  the  abdomen  not  to  injure  the  enlarged  uterus  just 
behind  the  anterior  wall ;  cutting  a  large  uterine  vein  would  seriously  complicate 
the  operation. 

4.  Be  careful  throughout  to  touch  and  handle  the  uterus  as  little  as 
possible.  It  is  best  not  to  lift  the  uterus  out  of  the  abdomen  if  it  can  be 
avoided.  If  the  large  uterus  must  be  drawn  out  in  order  to  reach  the  tumor, 
it  must  be  covered  with  gauze  and  kept  warm  by  pouring  hot  water  over  it 
frequently. 

5.  In  removing  an  ovarian  or  tubal  tumor  it  is  of  the  highest  importance  that 
the  vessels  at  both  ends  of  the  broad  ligament  should  be  tied  separately,  leaving 
an  interval  between ;  if  the  vessels  are  bunched  together  by  interlocking  liga- 
tures the  risks  of  hemorrhage  are  far  greater  than  ordinary. 

6.  The  superficial  layers  of  the  uterine  tissue  may  be  safely  incised  and 
sutured. 

7.  The  body  heat  should  be  kept  up  by  hot- water  bags  and  warm  blankets, 
and  the,  intestines  should  be  protected  from  exposure. 

8.  A  tendency  to  abort  will  be  best  obviated  by  using  enough  morphin  to 
keep  the  patient  quiet  and  free  from  pain  for  the  first  thirty-six  hours  or  lunger 
after  operation. 

9.  The  abdominal  bandage  must  be  snugly  fitted  and  with  great  care  to  give 
a  good  firm  support  to  the  abdominal  \valls  while  the  wound  is  healing. 

10.  Abortion  and  maternal  death  are  usually  due  to  sepsis. 
Indications   for  Operation  . — An  operation  is  demanded  in  general 

when  the  disease  produces  much  discomfort,  threatens  life,  or  renders  labor  dan- 


406  OPERATIOXS    DURING    PREGNANCY. 

ejerous  or  impossible,  or  when  the  tumor  is  apparently  malignant.     Operations 
during  pregnancy  may  be  called  for  under  the  following  conditions : 

(a)  Uterus  incarcerated  in  the  pelvis. 

(b)  Oyarian  cystoma. 

(c)  Parovarian  cyst. 

(d)  Dermoid  cyst. 

(e)  Solid  tumor  of  the  ovary. 

(f)  Uterine  myoma,  sessile,  and  pedunculated. 

(g)  Cancer  of  the  cervix. 

(h)  Pyosalpinx  and  ovarian  abscess. 

(i)  Appendicitis. 

(a)  Incarcerated  Uterus . — I  mention  here  the  pregnant  retroflexed 
uterus  incarcerated  in  Douglas's  cul-de-sac,  because  the  enlarged  fundus  felt  j^&r 
vaglnam  has  been  mistaken  for  a  tumor  behind  the  uterus,  as  in  a  case  of  E. 
Schwartz  {Ann.  de  Gyn.,  Oct.,  1894,  p.  241),  where  the  menses  were  regular 
and  the  uterus  appeared  to  be  compressed  between  a  tumor  filling  Douglas's 
pouch  and  the  symphysis.  A  celiotomy  was  done,  and  the  three  months'  preg- 
nant uterus  was  found  in  retroflexion.  The  flexion  was  corrected,  the  abdomen 
closed,  and  the  patient  went  to  term. 

Ordinarily  after  emptying  rectum  and  bladder  the  incarcerated  uterus  can 
be  readily  set  free  by  gentle  bimanual  manipulations  of  the  fundus  through  the 
vagina  or  rectum  and  the  abdominal  walls.  If  the  reposition  is  difiicult,  it  will 
be  facilitated  by  placing  the  patient  in  the  knee-breast  posture  (Sanger,  Cent./. 
Gj/n.,  1894,  p.  174),  filling  the  vagina  and  rectum  with  air,  and  then  gently 
manipulating  the  fundus  in  a  direction  out  through  the  superior  strait,  bearing 
in  mind  the  shelf  made  by  the  promontory  of  the  sacrum,  which  oifers  the  only 
serious  mechanical  resistance  when  there  are  no  adhesions  present. 

If  these  simple  maneuvers  do  not  succeed,  the  posterior  lip  of  the  cervix 
may  be  caught  with  tenaculum  forceps  and  drawn  down  toward  the  vaginal 
outlet,  with  the  patient  still  in  the  knee-chest  posture ;  this  has  the  effect  of 
straightening  out  the  uterus,  when  pressure  can  be  made  with  better  effect  on 
the  fundus,  which  is  easily  pushed  forward  into  the  su23erior  strait  by  two  fingers 
in  tlie  rectum.  The  cervix  is  then  carried  back  by  the  forceps  to  its  normal 
position  in  the  posterior  part  of  the  pelvis,  and  the  fundus  pushed  farther  for- 
ward ;  the  forceps  are  now  removed  and  the  patient  put  in  the  dorsal  position, 
when  the  fundus  can  be  brought  into  marked  anteflexion  by  pushing  the  cervix 
back  and  up  toward  the  promontory  w^ith  two  fingers  in  the  vagina,  while  the 
other  hand  draws  the  fundus  well  forward  through  the  abdominal  walls. 

Buchhold  reports  a  case  [Der  jprakt.  Arst.,  Band  xxxv,  No.  2  ;  see  Trommel, 
Jahresh.,  ix,  p.  558)  in  which  an  adherent  retroflexed  uterus  was  liberated  in  the 
fourth  month  of  pregnancy.  The  patient,  thirty -four  years  old,  was  suddenly 
seized  with  pain  in  the  lower  abdomen  and  sacral  region,  severe  constipation,  and 
difficult  urination.  An  attempt  at  reposition  failed,  and  in  twenty-four  hours 
vomiting  and  fever  set  in.  The  uterus  was  then  liberated  by  placing  the  patient 
under  anesthesia  and  introducing  the  whole  hand  into  the  vagina,  and  gradually 


OVARIAN",    PAROYARIAX,    AXD    DERMOID    CYSTS.  407 

forcing  the  fundus  up.  The  effect  was  to  rupture  the  adhesions  and  free  the 
uterus ;  the  pain  and  other  disabilities  disappeared,  and  the  pregnancy  continued 
to  its  normal  terminus. 

If  these  means  fail  to  right  the  uterus,  and  the  patient's  condition  does  not 
contra-indicate  it,  the  abdomen  should  be  opened  and  the  uterus  liberated  and 
brought  forward  (see  Michie's  case,  Brit.  Gryn.  Jour.^  ^^^g-i  1S95,  p.  164). 

(b,  c,  d,  e)  Ovarian,  Parovarian,  and  Dermoid  Cysts,  and 
Solid  Tumors  of  the  Ovary . — Ovariotomy  as  a  rule  is  the  simplest 
and  the  safest  abdominal  operation  in  pregnancy  to  both  child  and  mother ;  but 
its  dangers  are  increased  by  extensive  adhesions,  and  abortion  is  liable  to  be  pro- 
duced by  a  protracted  operation  with  much  manipulation  of  the  uterus.  It  is 
but  a  few  years  since  abortion  and  puncture  were  advocated  in  the  treatment  of 
tumors  com]3licatLng  pregnancy ;  now  abortion  is  no  longer  practiced,  and  punc- 
ture is  limited  to  those  cases  in  which  the  patient  is  actually  parturient.  A. 
Martin  has  even  operated  with  success  and  prevented  a  threatened  abortion. 
The  importance  of  the  tumor  varies  with  its  size,  position,  and  character.  A 
large  abdominal  tumor,  or  one  which  is  fixed  by  adhesions  in  the  pelvis,  forces 
an  immediate  operation.  Bilateral  tumors  and  small  hard  tumors  fixed  in  the 
pelvis  are  malignant  in  a  large  percentage  of  the  cases. 

W.  Heiberg  {Tumor  ovarii  in  graviditate^  Cen.  f.  Gyn.,  Ko,  26,  1882,  p. 
405)  has  shown,  in  a  collection  of  two  hundred  and  seventy-one  cases  of  ovarian 
cysts  complicating  pregnancy  which  were  not  interfered  with,  that 
over  one  fourth  of  the  mothers  and  two  thirds  of  the  children  died ;  in  marked 
contrast  to  this  stand  the  statistics  of  the  cases  operated  upon  during  pregnancy. 

Y.  Weiss  {Beitr.  s.  Chir.  Festschr.,  Th.  Billroth)  demonstrated,  from  a  study 
of  one  hundred  and  thirty -three  cases  of  ovariotomy  during  preg- 
nancy, a  maternal  mortality  of  7'4  per  cent. 

Dsirne  {Archiv.  f.  Gyn.,  J^o.  24,  p.  415)  collected  one  hundred  and  nine 
cases  with  5*9  per  cent  maternal  mortality  and  22  per  cent  abortions.  All  the 
cases  resulting  in  death  were  greatly  complicated  operations. 

F.  Mainzer  {Mi'mch.  med.  Woch.,  l^o.  48)  collected  seventeen  cases  of 
double  ovariotomy.  Three  times  abortion  was  produced  and  twice  pre- 
mature labor  came  on;  one  mother  died,  apparently  septic.  Twelve  of  the 
women  had  a  normal  labor  at  term. 

In  the  one  hundred  and  nine  cases  Dsirne  found  torsion  of  the  pedicle  ten 
times — that  is,  in  about  9  per  cent  of  the  cases. 

Tappingthe  ovarian  cyst  is  unjustifiable  in  view  of  the  excellent 
statistics  presented  by  operation,  except  when  the  patient  is  on  the  eve  of  or 
actually  in  labor,  and  the  pressure  exerted  by  the  tumor  or  the  obstruction  which 
it  offers  to  the  progress  of  labor  in  the  pelvis  demand  immediate  relief. 

The  following  case  of  my  own  exhibits  well  the  tolerance  of  the  pregnant 
uterus.  Pregnancy  of  four  months  in  a  woman  of  forty- 
two  after  thirteen  years'  sterility;  large  ovarian  cyst, 
with  hemorrhage;  numerous  adhesions;  operation,  cys- 
tectomy;   recovery,    delivery    at    term. 


408  OPERATIONS    DURING    PREGNANCY. 

M.  E.,  1188,  had  had  three  children,  the  youngest  thirteen  years  ago.  Her 
menstrual  periods  had  continued  with  slight  irregidarity  up  to  one  week  before 
her  entrance  into  the  hospital  for  the  removal  of  a  monocystic  ovarian  tumor 
about  the  size  of  a  seven  months'  jDregnancy,  filling  the  lower  abdomen  in  the 
center  and  rising  well  above  the  umbilicus.  On  opening  the  abdomen,  Feb.  3, 
1892,  the  tumor  was  found  extensively  adherent  to  the  abdominal  walls  as  well 
as  over  the  entire  posterior  pelvis  and  to  the  caput  coli.  The  brownish  color  of 
the  cyst  wall,  seen  as  soon  as  it  was  exposed,  was  the  indication  of  an  old  exten- 
sive hemorrhage  into  the  sac.  After  tapping  the  cyst  and  freeing  the  adhesions 
the  top  of  the  right  broad  ligament  was  tied  off  and  the  tumor  removed.  The 
small  left  ovary  and  tube  were  adherent  to  the  posterior  surface  of  the  uterus, 
which  was  in  about  the  fourth  month  of  pregnancy  and  was  crowded  over  to  the 
left  side.  After  checking  the  hemorrhage  from  bleeding  points  in  the  pelvis  by 
sutures,  the  abdomen  was  irrigated  with  salt  solution  and  closed  without  a  drain. 
The  patient  made  a  satisfactory  recovery,  left  the  hospital  in  four  weeks,  and 
was  delivered  at  term  after  a  normal  labor. 

Hydrosalpinx  and  ovarian  cyst,  H.  L.,  No.  1249,  aged  nineteen ; 
operation  in  the  third  month  of  pregnancy,  recovery,  delivery  at  term  without 
complication. 

The  patient  applied  for  relief  on  account  of  severe  lower  abdominal  pains, 
loss  of  weight,  constant  headaehe,  and  a  "lump"  she  had  discovered.  Her  last 
menses  were  three  months  previously.  At  the  operation,  Aug.  20,  1894,  a  right 
tube  and  ovary  with  a  large  cystic  Graafian  follicle  was  freed  from  adhesions 
binding  it  down  in  the  pelvis  and  removed.  The  left  side  was  healthy.  The 
pregnancy  continued  to  term. 

Parovarian  cysts  and  monocystic  tumors  obstructing 
labor  may  often  be  emptied  with  advantage  through  the  vagina  by  entering  a 
trocar  into  the  most  prominent  part. 

In  one  case,  S.  M.  (Ko.  2561,  Jan.  4,  1894),  I  removed  from  a  jmtient  in  the 
third  montli  of  pregnancy  a  parovarian  cyst  containing  1  liters  of  fluid.  Two 
small  cysts  were  also  removed  from  the  left  parovarium  without  taking  out  the 
tube  or  the  ovary.     The  pregnancy  continued  uninterrupted. 

Single  and  double  dermoid  tumors  may  also  give  rise  to  serious 
symptoms  during  pregnancy  ;  the  relative  frequency  of  dermoids  to  ovarian 
tumors  is  about  as  1  to  13'5.  The  results  of  operation  are  like  those  in  other 
ovarian  tumors. 

C.  Staude  [Monatsschr.  f.  Geh.  und  Gyn.,  Band  ii,  Heft  4)  reports  a  case  in 
which  he  removed  in  the  third  month  a  small  generally  adherent  dermoid  with- 
out interrupting  the  pregnancy. 

Dr.  B.  C.  Hirst  reports  an  interesting  case  {A7ner.  Jour,  of  01)st.,  1895,  p. 
224)  in  which  it  was  difficult  to  distinguish  between  a  possible  extra-uterine 
pregnancy,  a  retroflexed  pregnant  uterus,  or  an  ovarian  cyst  associated  with  in- 
tra-uterine  pregnancy.  At  the  operation  a  dermoid  cyst  was  found  on  the  left 
side  as  large  as  a  cocoanut,  with  one  twist  in  the  pedicle.  The  cyst  was  removed 
and  the  pregnancy  continued  uninterrupted. 


UTERINE    MYOMA.  409 

Mr,  R.  Morrison  {Brit  Gyn.  Jour.,  IMaj,  1895,  p.  92)  removed  two  der- 
moid tumors  in  a  woman  in  the  fourth  month  without  interfering  -with  the 
pregnancy. 

Dr.  C.  Jacobs  {Gaz.  med.  de  Paris,  1895,  No.  29)  removed  an  ovarian  cyst 
per  vaginam  by  incising  the  posterior  cid-de-sac  with  the  thermo-cautery,  emp- 
tying and  withdrawing  the  collapsed  sac  and  controlling  the  vessels  by  forceps, 
which  were  removed  on  the  third  day.  The  patient  was  allowed  to  get  up  on 
the  fifth  day,  and  the  pregnancy  continued  undisturbed. 

I  know  of  no  other  case  like  the  following,  in  which  I  removed  a  fibroid 
tumor  of  the  left  ovary,  June  21,  1893  (A.  R.,  E'o.  2042),  from  an 
unmarried  woman  of  twenty  two  years,  who  was  six  months  pregnant.  The  ovoid 
mass,  12  X  T  centimeters,  was  wedged  in  the  pelvis  and  could  not  be  displaced 
by  efforts  made  through  the  vagina.  The  cervix  was  compressed  and  forced  high 
up  behind  the  horizontal  pubic  ramus.  An  abdominal  incision  17  to  18  centi- 
meters long  was  made,  and  the  pregnant  uterus  lifted  out  and  drawn  forward  so 
that  the  body,  covered  ^vith  hot  gauze,  rested  on  the  pubes,  while  the  lobulated 
dense  white  ovarian  mass  was  extracted  from  the  pelvis  and  its  broad  pedicle  tied 
off.  Although  the  entire  operation  lasted  forty -six  minutes,  and  the  incision 
was  a  long  one,  and  the  uterus  was  handled  as  described,  the  patient  recovered 
without  the  slightest  symptom  of  an  abortion  and  traveled  several  hundred  miles 
home,  where  I  understand  an  abortion  was  practiced  two  or  three  months  later. 

(f)  U  t  e  r  i  n  e  Myoma . — Scarcely  any  gynecological  question  is  of  greater 
interest  than  the  proper  attitude  of  the  surgeon  toward  the  pregnant  myomatous 
uterus. 

The  radical  views  of  the  profession  at  large  are  only  too  evident  from  the 
numerous  cases  reported  in  which  fibroid  uteri  have  been  successfully  extirpated 
in  the  first  six  months  of  pregnancy. 

The  frequency  of  pregnancy  is  well  shown  by  the  following  statistics  of  my 
own  cases  prepared  by  Dr.  J.  H.  Durkee :  Two  hundred  and  sixty-six  married 
women  with  myomatous  uteri  had  542  pregnancies,  out  of  which  there  Avere  402 
children  born  at  term  and  140  miscarriages ;  the  average  number  of  pregnancies 
was  therefore  2"03  per  cent. 

It  often  happens  that  the  existence  of  the  myomata  is  discovered  for  the 
first  time  during  pregnancy.  This  is  niost  liable  to  occur  when  the  tumors  are 
attached  to  the  anterior  surface  of  the  body  of  the  uterus,  because,  as  the  womb 
rises  into  the  al)domen  and  comes  into  close  contact  with  the  anterior  wall,  any 
irregularities  or' bosses  on  the  surface  become  conspicuous  and  are  easily  felt. 

In  many  cases,  after  one  or  more  pregnancies,  the  myomata  then  grow  so 
rapidly  as  to  fill  the  lower  abdomen  in  a  few  years.  A  form  which  is  met  often 
enough  to  be  characteristic  of  this  class  is  the  single  large  spherical  myoma, 
choking  the  pelvis  or  rising  up  to  the  umbilicus,  the  size  of  a  man's  head  (see 
Fig.  483). 

The  following  rules  should  be  observed  regarding  any  surgical  interference 
with  the  uterus  before  the  last  months  of  pregnancy — that  is  to  say,  before  the 
viability  of  the  child  : 


410  OPERATIONS    DURING    PREGNANCY. 

(a)  Always  remember  that  two  lives  are  involved,  and,  if  possible,  save  both, 
rejecting  all  radical  measures  unless  the  symptoms  are  urgent.  Mere  prophy- 
laxis— that  is  to  say,  operating  when  there  are  no  urgent  symptoms  on  account 
of  dangers  which  may  arise — has  no  field  here. 

(b)  Small  and  medium-sized  fundal  fibroids  do  not  demand  operation. 

(c)  Intraligamentary  and  subperitoneal  cervical  fibroids  do  not  demand  opera- 
tion unless  of  such  a  size  and  so  located  as  to  encroach  upon  the  pelvic  room  or 
the  superior  strait  in  such  a  way  as  to  prevent  labor.  Pediculated  fibroid  tu- 
mors which  can  be  pushed  up  into  the  abdomen  do  not  justify  hiterference  dur- 
ing pregnancy. 

(d)  Interstitial  tumors  should  not  be  touched  if  the  operation  can  possibly  be 
avoided,  for  they  require  so  much  handling  and  suturing  of  the  uterus  that  abor- 
tion almost  necessarily  follows  their  removal. 

(e)  Operation  may  be  demanded  on  account  of  extreme  pain  caused  by  a 
fibroid  tumor. 

(f)  Operation  may  also  be  called  for  on  account  of  the  rapid  growth  of  the 
tumors  during  pregnancy. 

(g)  Pediculated  fibroid  tumors  (polyps)  hanging  out  of  the  cervix  into  the 
vagina  may  be  removed  with  safety. 

(h)  When  the  patient  has  gone  almost  to  term,  if  the  fibroid  masses  are  so 
large  as  to  necessitate  a  subsequent  hysterectomy  in  case  they  are  left,  then  it  is 
better  to  deliver  the  child  by  a  Csesarean  operation,  and  to  remove  the  uterus  at 
the  same  time. 

The  greatest  risk  of  error  in  these  cases  is  in  removing  a  uterus  with  fibroids 
where  the  tumors  might  at  a  later  date  be  removed  without  the  sacrifice  of  the 
uterus.  A  sessile  tumor  so  placed  in  the  pelvis  as  to  obstruct  labor  may  be 
removed  without  much  risk  of  causing  abortion.  I  have  performed  myo- 
mectomy for  sessile  fibroids  before  the  sixth  month  three  times 
successfully,  and  without  interrupting  the  pregnancy  in  any  case. 

An  example  of  these  operations  was  M.  S.  (No.  1249),  three  months  preg- 
nant, myoma  about  5  centimeters  in  diameter,  sessile  on  the  posterior  surface  of 
the  uterus  about  the  cervical  junction.  At  the  oj)eration  (March  10,  1892),  after 
exposing  the  tumor  by  an  abdominal  incision  8  centimeters  long,  it  was  shelled 
out  through  an  incision  in  its  capsule  and  the  edges  of  the  incision  brought 
together  by  about  eight  silk  sutures,  and  the  abdomen  closed  without  a  drain. 
The  pregnancy  continued  undisturbed  to  term. 

G.  Aime  (see  Nouv.  Arch.  cVOls.  et  de  Gyn.,  Sup.  ]^o.  4,  p.  190)  reports  an 
abdominal  extirpation  of  a  right  intraligamentary  tiimor  re- 
moved in  the  third  month  without  interrupting  the  pregnancy. 

Another  instance  is  recorded  by  R.  Frommel  {MuncTi.  med.  Woeh.,  l^o.  14, 
1893,  p.  262)  in  which  he  removed  a  left-sided  intraligamentary  myoma.  The 
tumor  lay  for  the  most  part  above  the  pelvis  and  filled  the  superior  strait.  The 
enucleation  was  easy,  and,  after  stopping  all  the  hemorrhage,  the  walls  of  the 
sac  were  stitched  firmly  together.  The  recovery  was  uninterrupted  and  the 
pregnancy  went  to  term. 


CAXCER    OF   THE    CERVIX.  411 

W.  J.  Taylor  {A?m.  of  Gyn.  and  Fed.,  1892,  p.  92)  operated  u^on  an  in- 
traligainentarj  myoma  in  a  twin  pregnancy  in  the  fourth  month,  removing  at 
the  same  time  two  small  subserous  myomata.  Drainage  was  used,  and  the  pa- 
tient aborted  in  six  days. 

Violent  abdominal  pain  was  the  indication  for  operation  upon  a 
pediculated  myoma  in  the  fifth  month  in  a  case  of  Frommel's,  where  the  patient 
had  been  unable  to  leave  her  bed  for  three  months. 

Kirchheimer  {Inaug.  Dhs.^  Halle,  1895)  estimates  a  mortality  of  18'87  per 
cent  in  myomectomy  for  pediculated  fibroids,  and  26  per  cent  in  supravaginal 
amputation  of  pregnant  fibroid  uteri,  while  premature  interruption  of  the  preg- 
nancy causes  as  high  a  mortality  as  40  per  cent. 

A.  L.  Stavely  {Neio  York  Jour,  of  Gyn.  and  Obst.,  June,  1894)  has  shown 
that  seventeen  cases  operated  on  between  1889  and  1894  gave  a  death  rate  of 
11-75  per  cent — results  which  he  rightly  attributes  to  better  technique. 

When  the  patient  is  in  the  last  months  of  pregnancy  and  the  fibroid  uterus 
is  one  to  require  operation,  the  best  plan  is  to  open  the  abdomen  by  an  incision 
large  enough  to  lift  the  uterus  with  all  the  tumors  outside,  and  then  to  clamp  all 
the  ovarian  vessels  near  the  pelvic  brim,  using  two  clamps  on  each  side  and 
cutting  between  them ;  the  round  ligaments  are  then  clamped  distally  and  cut 
loose,  and  both  broad  ligaments  pushed  down ;  a  rubber  ligature  thrown  tight 
around  the  cervical  portion  of  the  uterus  controls  the  uterine  vessels,  while  the 
uterine  canity  is  opened  between  the  tumors  through  the  thinnest  part  of  the 
walls  and  the  child  extracted.  If  the  bladder  is  disjjlaced  it  must  be  freed 
and  pushed  down  into  the  pelvis  before  placing  the  provisional  ligature  around 
the  uterine  vessels.  A  slow  operator  will  do  better  to  liberate  the  child  first, 
clamping  and  cutting  the  cord,  and  leaving  the  placenta  in  dtii.  He  may 
then  proceed  with  a  ligation  of  the  vessels  and  the  supravaginal  amputation 
of  the  uterus  as  described  in  Chapter  XXYIII.  Drainage  ought  not  to  be 
used. 

(g)  C  a  n  c  e  r  of  the  Cervix  .—Fortunately  for  the  mother,  pregnancy 
but  rarely  occurs  in  a  cancerous  uterus  ;  the  mechanical  barrier  afforded  by  the 
enlarged  choked  cervix,  and  the  chemical  barrier  of  the  infected  secretions, 
seem  in  most  cases  to  afford  a  suflScient  protection  against  this  accident. 

AVhen  pregnancy  does  occur,  the  increased  vascularity  and  opening  up  of  the 
lymph  channels  often  causes  a  rapid  advancement  of  the  disease. 

The  cardinal  rule  should  be,  therefore,  when  a  radical  operation 
is  possible,  to  do  it  at  the  earliest  opportunity  in  the  in- 
terest of  the  mother. 

AYhen,  on  the  contrary,  the  disease  is  too  advanced  to  offer  the  hope  of  its 
entire  enucleation,  every  effort  must  l)e  made  to  save  the  child  by  allowing  the 
pregnancy  to  go  on  to  term,  or  near  it,  and  delivering  the  child  by  Csesarean 
section. 

The  dangers  of  infection  are  great  after  such  an  operation,  and  nnist  be  pro- 
vided against  by  removing  as  much  of  the  disease  as  possible,  which  also  gives 
better  vaginal  drainage.     It  is  also  well  to  insert  into  the  uterus  through  the 


412  OPERATIONS    DURING    PREGNANCY. 

vagina  a  drain  of  washed-out  iodoform  ganze,  and  to  irrigate  the  uterus  freely 
on  the  first  appearance  of  sepsis. 

(h)  Pyosalpinx  and  Ovarian  Abscess . — The  distortion,  adhesions, 
and  occhision  of  the  tubes  produced  by  a  pelvic  abscess  are  so  great  that  preg- 
nancy bat  rarely  occurs,  and  then,  as  a  rule,  the  patient  either  aborts  early  or 
lives  in  imminent  danger  from  the  breaking  of  the  adhesions  and  the  rupture  of 
the  abscess  as  the  womb  enlarges.  It  is  not  long  since  the  general  impression 
prevailed  that  ^jregnancy  could  not  occur  either  in  the  presence  of  a  pyosalpinx 
or  if  the  tubes  were  in  a  condition  to  develop  a  pyosalpinx,  but  this  error  has 
been  abundantly  disproved  by  clinical  facts.  Kaltenbach  saw  a  case  of  pyosal- 
pinx rupture  during  the  expression  of  the  placenta  by  Crede's  method,  with  the 
result  of  a  septic  peritonitis  and  death. 

The  rule  of  treatment  is  in  all  cases,  without  exception, 
either  to  evacuate  the  abscess  or  to  extirpate  the  sac  at 
the  earliest  possible  moment. 

When  the  abscess  can  be  felt  in  the  pelvis  behind  the  uterus,  it  should  be 
opened,  thoroughly  cleaned  out,  and  drained  through  a  free  incision  into  the 
cul-de-sac,  but  when  a  pyosalpinx  has  ascended  into  the  abdomen  on  the  grow- 
ing womb  it  must  be  removed  by  abdominal  section. 

H.  Michie  {Brit.  Gyn.  Jour.,  ^^ig-?  1895,  p.  194)  reports  two  cases  of 
operation  for  the  relief  of  suppurating  appendages  during 
pregnancy. 

In  one  case,  a  young  woman  who  had  ceased  to  menstruate  four  months  be- 
fore, suffered  from  pain  in  the  left  iliac  region  with  painful  defecation.  The 
uterus  was  found  enlarged,  retroverted,  and  fixed,  with  a  tender  swelling  behind 
and  to  the  left  side;  both  appendages  were  removed  by  celiotomy,  the  right 
inflamed  and  thickened,  and  the  left  containing  pus.  The  uterus  was  freed  and 
brought  forward ;  the  patient  recovered  and  passed  through  a  natural  labor  at 
term. 

In  another  case,  a  multipara,  aged  forty,  both  appendages  were  removed  for 
pyosalpinx  between  the  fourth  and  fifth  months  of  pregnancy.  The  patient 
objected  to  operation  until  the  symptoms  became  alarming,  when  it  j^roved  to 
be  too  late  to  be  beneficial  and  she  died  of  acute  septic  peritonitis  on  the  sixth 
day. 

In  a  case  of  Kaltenbach's  (R.  Kroesing,  Inaug.  Diss.,  ITallc,  1800)  a  patient 
thirty-eight  years  old,  Vlll-para,  and  about  seven  months  pregnant,  was  sud- 
denly seized  with  severe  intermittent  pains  in  the  right  lower  abdomen,  nausea, 
and  fainting  spells ;  four  days  later  an  examination  showed  the  presence  of  re- 
sistance and  dullness  extending  from  the  lower  border  of  the  liver  to  the  ileo- 
cecal region.  The  pulse  was  120  and  the  temperature  39°  C.  On  the  fifth  day 
after  the  attack  the  abdomen  was  opened  in  the  linea  alba,  and  the  right  tube 
found  much  thickened,  cyanotic,  and  dilated,  the  central  point  of  a  marked  sur- 
rounding peritonitis  ;  there  were  numerous  deposits  of  lymph  on  the  peritoneum 
and  some  exudate  in  the  dependent  j^arts.  The  vermiform  appendix  was  nor- 
mal.    The  friable  tube  was  removed  and  the  patient  recovered.     She  miscar- 


APPEXDICITIS.  413 

ried  on  the  day  following  the  Oi^eration,  giving  birth  to  a  small  living  female 
child  weighing  1,100  grammes. 

In  a  case  operated  upon  by  Dr.  H.  C.  Coe,  from  three  and  a  lialf  to  four 
months  pregnant,  the  adhesions  bhiding  down  the  pelvic  structures  were  found 
to  be  so  dense  that  it  was  impossible  to  remove  them ;  a  pelvic  abscess  was  then 
opened  and  drained  through  the  vagina,  and  the  patient  recovered  and  aborted  a 
month  later. 

Dr.  J.  :SL  Baldj  {Tram.  Phila.  Co.  Med.  Soc,  1893)  operated  upon  a 
woman  who  had  been  in  an  insane  asylum  for  menstrual  insanity ;  she  was  five 
months   pregnant,  and    had   an    abscess    in    the    uterine   wall,   with 

pyosalpinx  on  both  sides,  each  containing  the  same  amount  of  pus 

about  30  cubic  centimeters.  Both  tubes  and  ovaries  were  removed  after  freeing 
numerous  adhesions,  and  the  abscess  in  the  uterus,  which  was  opened  by  sepa- 
rating an  adherent  omentum,  was  cleansed,  curetted,  and  sterilized  by  a  bichlo- 
ride of  mercury  solution  (1  to  1,500),  and  the  edges  brought  together  by  silk 
sutures.  The  abdomen  was  closed  without  drainage,  and  the  patient  made  an 
easy  convalescence,  in  spite  of  a  week's  insanity,  and  was  delivered  at  term  with- 
out any  complications. 

Suppurating  ovarian  and  suppurating  dermoid  cysts 
also  occur  during  pregnancy,  and,  by  the  urgency  of  the  symptoms,  pain,  peri- 
tonitis, and  elevation  of  temperature,  leave  no  room  for  hesitation  as  to  the 
necessity  for  immediate  operation. 

(i)  Appendicitis  . — Inflammation  of  the  vermiform  appendix  may  occur 
in  pregnancy,  as  the  condition  offers  no  immunity  from  the  disease ;  an  instance 
of  rupture  of  the  vermiform  appendix  and  death  during  j^regnancy  was  referred 
to  by  Clement  Godson  in  the  discussion  of  Mr.  Michie's  paj)er  (Brit.  Gyn. 
Jour..,  August,  1895,  p.  169). 

I  have  in  my  own  experience  seen  two  eases  of  pregnant  women,  both  con- 
fined to  bed  by  a  localized  jDain  and  tenderness  in  the  right  iliac  fossa,  and  with 
some  elevation  of  temperature,  and  presenting  a  history  of  previous  similar  at- 
tacks. The  diagnosis  of  appendicitis  was  made,  but  no  operation  was  necessarv, 
and  both  women  were  delivered  at  term. 

Dr.  P.  F.  Munde  reports  a  case  {M<^d.  Becord,  Dec.  1,  1894,  p.  f»78)  of  ap- 
pendicitis occurring  in  the  last  month  of  a  first  pregnancy.  The  patient  had  pain 
and  tenderness  in  the  lower  abdomen  equally  severe  in  the  median  line  and  on 
both  sides,  with  a  temperature  of  lo2°  F.  (38-9°  C.)  on  the  fourth  day.  On  the 
sixth  day  "  she  was  seized  with  atrocious  pains  in  the  pelvic  region,  accompanied 
by  a  pronounced  chill,  and  a  temperature  of  101-5''  F.;  at  the  same  time  labor 
pains  began,"  and  she  was  delivered  of  a  dead  child  in  about  eighteen  hours. 
Twelve  hours  later  decided  dullness  and  acute  pain  on  pressure  were  found  in 
the  right  iliac  region,  without  any  tenderness  or  mass  near  the  vaginal  vault. 

Six  days  after  delivery  an  abscess  walled  off  by  intestines  was  opened  here 
and  drained.     After  this  the  recovery  was  uneventful. 

Two  instructive  cases  are  also  reported  by  Dr.  L.  L.  ^McArthur  {Aiiwr.  Jour, 
of  Ohs.^  Feb.,  1895,  p.  181),  one  of  them  four  and   a  half  and  the  other  five 


414:  OPERATIONS    DURIXG    PREGNANCY. 

months  pregnant ;  a  gangrenous  appendix  was  found  in  the  first  case,  a  dead 
fetus  was  expelled  the  day  after  operation,  and  on  the  following  day  the  mother 
died  of  a  general  peritonitis.  In  the  second  case  a  tumor  existed  in  the  right 
iliac  fossa  and  the  right  vaginal  vault ;  at  the  operation  the  uterus  was  found  to 
form  the  inner  wall  of  a  fetid  abscess ;  the  patient  had  a  miscarriage,  and  died  on 
the  fifth  day  of  peritonitis. 


CHAPTER  XXXIII. 

CESAREAN   SECTION. 

1.  Indications  for  the  operation,  absolute  and  relative. 

2.  Competitive  operations — induction  of  premature  labor,  use  of  forceps,  turning,  symphyseotomy, 

craniotomy. 

3.  The  conservative  Cesarean  operation  :  1.  Preparation  and  instruments.     2.  The  abdominal  and 

uterine  incision.  3.  Delivery.  4.  Clamping  the  cord.  5.  Control  of  hemorrhage.  6.  De- 
livery of  the  placenta  and  membranes.  7.  The  uterine  suture.  8.  Cleansing  the  peri- 
toneum. 9.  Closure  of  the  abdominal  wound.  10.  Duration  of  the  operation.  11.  Errors 
in  technique.     12.  After  care. 

4.  The  Porro-Cesarean  operation  :  1.  Three  ways  of  operating.    2.  Operation,    a.  Second  method. 

b.  Third  method — panhysterectomy. 

The  Cesarean  section  is  a  surgical  operation  by  which  the  child  is  delivered 
from  the  uterus  by  an  abdominal  section.  It  stands  in  contrast  to  all  forms  of 
delivery  through  the  vagina,  as  well  as  to  delivery  through  the  abdomen  when 
the  child  has  escaped  into  the  cavity  through  a  ruptured  uterus. 

The  indications  for  the  Cesarean  section  are  either  absolute  or  rela- 
tive. The  indication  is  absolute  when  there  is  no  alternative  and  delivery  ^:>^/' 
vias  naturales  can  not  be  effected  ;  it  is  relative  when  there  is  a  choice  between 
this  and  various  other  procedures,  such  as  the  induction  of  premature  labor, 
turning,  the  use  of  forceps,  symphyseotomy,  or  craniotomy. 

The  indication  is  absolute  and  the  Cesarean  section  must  be  per- 
formed when  there  is  a  living  child  in  a  flattened  pelvis  with  a  true  conjugate 
diameter  of  6*5  centimeters  (2|-  inches)  or  less,  or  in  a  generally  contracted  pelvis 
of  7  to  7'5  centimeters  or  less,  and  in  case  the  child  is  dead  in  a  j)elvis  measuring 
4*5  centimeters  (If  inch)  or  less. 

The  indication  is  relative  and  the  Cesarean  section  enters  into 
competition  as  an  alternative  with  craniotomy,  when  the  child  is  alive,  when  the 
conjugate  diameter  runs  from  5  or  5*5  to  7'5  centimeters. 

Craniotomy  must  be  selected  in  all  cases  where  the  child  is  dead  and  the 
conjugate  diameter  measures  from  i-S  centimeters  (If  inch)  up. 

Symphyseotomy  competes  with  the  induction  of  premature  labor  cliiefly 
in  pelves  whose  conjugate  diameters  measure  7  centimeters  (24  inches)  or  more. 
Where  the  conjugate  diameter  is  less  than  7  centimeters  it  is  a  hazardous  opera- 
tion, unless  the  child's  head  is  small. 

Turning,  followed  by  immediate  delivery,  is  best  limited  to  cases  in  which 
the  true  conjugate  diameter  measures  from  8*5  to  9'5  centimeters  (3|  to  .S| 
inches) ;  it  may  be  successful  in  the  case  of  a  small  child  with  dilated  cervix  and 
unru]itured  waters,  in  flat  rachitic  pelves  of  7  centimeters  (2|^  inches),  or  in  gen- 
erally contracted  pelves  of  7'r>  centimeters  (3  inches). 

415 


416  CESAREAN    SECTION. 

Tlie  induction  of  premature  labor  is  performed  wliile  the  fetus 
is  viable,  between  the  twentj-eiglitli  and  thirty-sixth  weeks,  in  pelves  measuring 
6*5  to  8  centimeters  (2"0  to  3*2  inches)  in  the  conjugate  diameter.  As  I  have 
just  said,  this  procedure  enters  into  competition  with  sym^^hyseotomy,  which 
should  be  performed  if  the  parents  wish  to  have  a  living  child. 

The  Tarnier  axis-traction  forceps  are  useful  in  all  cases  of 
contraction  of  the  pelvis  of  lesser  degree. 

The  relationship  between  spontaneous  labor,  a  high  forceps  operation,  induced 
labor,  symphyseotomy,  and  the  Cesarean  section,  in  the  same  woman,  is  well 
shown  by  a  case  of  my  own  in  Philadelphia  (K.  G.),  that  of  a  woman  with  a  flat- 
tened pelvis  with  a  true  conjugate  diameter  of  6*5  to  7  centimeters.  The  first 
child,  born  after  nineteen  hours  of  difficult  labor  ended  by  the  forceps,  was  so 
severely  injured  that  it  died.  The  second  child  was  a  puny  girl,  born  alive, 
without  assistance,  after  fourteen  hours  of  severe  labor  pains.  The  third  deliv- 
ery. May  30,  1888,  was  a  Cesarean  section  j^erformed  by  me  at  the  Kensington 
Hospital  for  Women,  after  consultation  with  Dr.  K.  P.  Harris  ;  the  child  weighed 
six  pounds  and  fifteen  ounces.  The  fourth  child  was  delivered  by  a  high  aj^pli- 
cation  of  the  forceps  by  Dr.  C.  P.  N'oble,  in  the  Kensington  Hospital,  after  the 
induction  of  labor  at  the  thirty-sixth  week.  This  baby  weighed  five  and  one 
thirty-second  pounds,  and  the  labor,  lasting  twenty-seven  and  a  half  hours,  was 
characterized  by  Dr.  N^oble  as  extremely  difficult.  The  fifth  labor  was  a  sym- 
physeotomy followed  by  a  difficult  high  application  of  the  forceps ;  this  was 
also  conducted  by  Dr.  Noble.  The  weight  of  the  baby  was  eight  and  a  half 
pounds. 

It  is  manifest,  from  the  statement  of  the  character  of  each  of  these  labors  in 
a  pelvis  contracted  to  this  degree,  that  the  two  plans  of  treatment  worthy  of 
most  consideration  as  giving  the  child  a  maximum  chance,  without  great  risk 
to  the  mother,  are  the  Cesarean  section  and  symphyseotomy.  It  is  not  possible 
at  present  to  state  positively  which  of  these  operations  will  in  the  future  have 
the  precedence  under  such  circumstances  as  these ;  my  own  preference  is  for  the 
Cesarean  section. 

The  Cesarean  operation  includes  under  one  name  two 
procedures  having  in  view  the  same  object  with  regard 
to  the  child,  but  radically  different  in  the  effect  upon 
the  mothe r — the  conservative  "  Sanger-Cesarean "  operation,  preserving  the 
uterus  (see  Der  Kaisersclmitt^  Leipzig,  1882),  and  the  radical  "  Porro-Cesarean  " 
operation,  completed  l)y  a  removal  of  the  uterus. 

Conservative  Cesarean  Operation. — The  conservative  Cesarean  operation  is  to 
be  performed  in  all  cases  when  the  true  conjugate  diameter  measures  6*5  centi- 
meters (2|  inches)  or  less,  with  a  living  child,  and  4*5  centimeters  (If  inch)  with 
a  dead  child.  This  narrowing  may  be  due  to  a  simple  deformity  in  the  diam- 
eters of  the  pelvis,  or  it  may  be  produced  by  a  bony  tumor  of  the  sacrum,  as  in 
one  of  my  cases  (M.  S.,  May  10,  1889),  where  the  pelvic  cavity  was  so  filled  out 
with  an  osteosarcoma  that  the  only  remaining  space  was  a  narrow  ellipse  2  centi- 
meters (f  inch)  in  diameter  at  its  widest  part  (see  Fig.  516). 


COXSERVATIVE    CESAREAN    OPERATION.  417 

In  another  ease  of  a  simple  flat  pelvis  (E.  J.,  April  17,  1888)  the  patient  had 
been  in  labor  for  two  weeks,  the  w^aters  had  ruptured  four  days  before  opera- 
tion, and  tlie  lower  pelvis  was  so  choked  by  the  swollen,  hard,  inflamed  con- 
nective tissue  that  the  inferior  strait  was  practically  obliterated  and  nothin^^ 
could  be  distinguished  by  the  vagina ;  Cesarean  section  was  absolutely  neces- 
sary to  save  the  mother's  life.  For  an  account  of  the  three  cases  here  cited, 
see  Amer.  Jour.  Ohst.,  March,  1890,  vol.  xxiii,  No.  3.  This  one  was  the  first 
successful  conservative  Cesarean  section  in  Philadelphia  after  Prof.  Gibson's 
case  referred  to  below. 

Another  indication  is  the  extensive  contraction  of  the  vagina  by  cicatricial 
tissue,  making  the  birth  impossible  per  vias  nahirales.  This,  however,  must 
only  be  accepted  with  extreme  caution,  as  successful  deliveries  have  often  been 
effected  where  the  cicatrices  seemed  impassable. 

The  best  time  to  operate  is  at  the  end  of  pregnancy,  and  after  labor 
has  been  so  long  in  progress  that  the  contraction  ring  has  formed,  and,  if  possi- 
ble, the  cervix  is  well  dilated.  It  is  better  that  the  bag  of  waters  should  not  be 
broken,  as  it  facilitates  the  delivery  if  the  child  is  taken  swimming  in  the 
amnion. 

Owing  to  the  uncertainty  of  the  precise  day  of  labor  and  the  awkwardness 
of  the  hour — often  late  in  the  night — and  the  difiiculties  of  preparation  and 
getting  assistance,  I  have  ventured  in  my  own  cases  to  operate  at  the  end  of 
pregnancy  without  waiting  for  the  pains  to  come  on.  In  doing  this  I  \dolated 
the  old-established  notion  that  the  woman  must  be  some  time  in  labor  in  order  to 
insure  good  uterine  contraction  afterward,  and  so  to  escape  the  danger  of  hem- 
orrhage. I  met  wdth  no  such  accident,  and  all  the  cases  did  well.  I  would 
therefore  recommend,  whenever  the  end  of  pregnancy  can  be  accurately  fixed 
by  reference  to  the  cessation  of  menstruation  and  measurements  of  the  child, 
that  the  operator  fix  the  day  and  hour  himseK,  and  make  all  his  arrangements 
as  for  any  other  operation. 

Preparation  and  Instruments . — Before  operating,  a  careful  exami- 
nation should  be  made,  determining  the  fact  that  the  child  is  living,  and  the 
exact  position  of  the  body  and  head,  as  well  as  the  position  of  the  placenta, 
determined  by  palpation  and  auscultation.  All  necessary  peh^c  and  fetal  meas- 
urements should  be  made  and  recorded  at  the  time  the  operation  is  under 
consideration :  distance  between  anterior  superior  iliac  spines ;  distance  between 
iliac  crests ;  external  conjugate,  Baudelocque's  diameter,  and,  when  possible,  the 
internal  conjugate,;  distance  between  trochanters,  and,  in  special  cases,  measure- 
ments at  the  j)elvic  outlet.  The  height  of  the  patient  and  any  deformity  nmst 
be  carefully  described,  and  the  length  of  the  flexed  child  iti  utero,  and  the  esti- 
mated biparietal  diameter  of  the  head. 

The  patient  should  be  prepared  by  diet,  regulation  of  the  bowels,  and 
daily  warm  Ijaths,  exactly  as  for  any  other  abdominal  operation. 

When  the  case  is  one  of  emergency,  all  previous  preparation  may  be  dis- 
pensed with ;  but  in  this  case  extra  precautions  must  be  taken  in  the  imme- 
diate preparations.     Just  before  the  operation,  when  the  patient  is  completely 


418  CESAREAN    SECTION. 

anesthetized,  the  whole  abdomen  is  thoroughly  washed  and  the  vagina  care- 
fully douched  with  a  ten  per  cent  creolin  solution. 

The  operator  stands  on  one  side  of  the  table  and  opposite  to  him  his  first 
assistant,  who  gives  his  closest  attention  throughout  to  the  uterus  and  the  ab- 
dominal and  uterine  wounds.  This  necessitates  one  or  two  other  assistants  be- 
hind him  to  hand  instruments,  needles,  ligatures,  and  sponges.  A  competent 
assistant  also  stands  by  the  operator,  ready  to  take  the  baby  as  soon  as  it  is  de- 
livered. It  ^vill  be  safer  if  all  the  assistants  wear  rubber  gloves  throughout,  and 
the  operator  should  do  the  same  if  there  is  the  slightest  suspicion  as  to  the  con- 
tamination of  his  hands. 

The  vagina  is  thoroughly  cleansed  and  loosely  filled  with  iodoform  gauze 
when  the  patient  is  put  upon  the  operating  table. 

The  Abdominal  and  Uterine  Incision . — An  incision  about  20 
centimeters  long  is  made  through  the  abdominal  wall  in  the  linea  alba  over 
the  most  prominent  part  of  the  uterine  enlargement;  this 
generally  falls  one  third  above  and  two  thirds  below  the  umbilicus,  or  even  as 
much  as  half  above  and  half  below  it,  when  the  uterus  stands  high.  Care  must 
be  taken  not  to  cut  through  the  abdominal  wall  too  quickly,  for  fear  of  cutting 
the  uterus.  Even  the  fetus  has  been  injured  in  this  way  by  an  injudicious 
stroke. 

As  soon  as  the  peritoneum  is  opened  the  red  convex  surface  of  the  uterus 
fills  the  incision.  The  assistant  now  presses  the  walls  on  both  sides  into  close 
contact  with  the  uterus,  and  keeps  up  this  apposition  during  the  delivery  and 
until  the  uterus  is  empty  and  contracted  so  as  to  protect  the  abdominal  cavity 
from  the  contamination  of  the  uterine  contents.  If  there  is  doubt  whether  the 
case  is  already  septic  or  not,  it  is  better  to  enlarge  the  abdominal  incision  so  as  to 
bring  the  uterus  outside  the  body  before  opening  it,  taking  care  to  protect  the 
incision  and  the  abdominal  cavity  behind  the  uterus  with  abundant  gauze  and 
towels  until  the  uterine  wound  is  closed. 

Ordinarily  the  uterus  is  incised  in  situ,  from  the  fundus  down  to  the 
reflection  of  the  vesical  peritoneum,  which  is  readily  recognized  as  a  white 
transverse  line  in  the  cervical  region.  The  incision  should  be  made  as  nearly 
as  possible  just  under  the  abdominal  incision  or  a  little  to  one  side  or  the 
other  to  avoid  the  placental  site,  which  may  be  recognized  by  an  increased 
vascularity  or  a  slight  elevation  during  uterine  contraction  and  a  doughy  feel- 
ing on  pressure. 

Fritsch,  of  Bonn,  recommends  making  a  transverse  incision  through  the 
fundus  of  the  uterus. 

If  the  placenta  lies  directly  under  the  incision  (placenta  prsevia  Ce- 
sariana),  as  it  does  in  about  half  the  cases,  it  will  be  recognized  by  the  villi 
pouting  into  the  wound,  and  care  nmst  be  taken  not  to  cut  its  vessels  and  deplete 
the  circulation  of  the  child.  A  further  objection  to  cutting  through  the  placen- 
tal site  is  the  increased  amount  of  hemorrhage. 

The  thin  uterine  wall  is  cut  through  in  one  place  slowly  but  deliberately  until 
the  dark  surface  of  the  uncut  amnion  appears. 


CONSERVATIVE    CESAREAN    OPERATION.  419 

The  Delivery  of  the  Child . — The  amnion  is  punctured  with  a 
knife,  and  as  the  fluid  is  escaping  two  fingers  are  inserted  within  the  uterus, 
lifting  up  the  edges  of  the  cut  while  it  is  enlarged  up  to  the  fundus  and  down 
to  the  cervical  region,  the  assistant  all  the  while  keeping  the  abdominal  walls 
pressed  in  on  the  collapsing  womb.  The  baby  is  now  grasped  bj  both  feet  and 
lifted  out  through  the  uterine  and  abdominal  incisions,  taking  care  not  to  tear 
the  womb  by  hurrying  too  much.  If  an  arm  is  caught  by  mistake  it  must  be 
put  back  and  the  feet  sought  for,  as  an  arm  dehvery  necessitates  dragging  the 
child  out  crosswise.  If  the  placenta  lies  just  under  the  incision  in  the  womb  it 
must  not  be  cut  through,  but  the  fingers  must  be  passed  to  its  nearest  border 
and  the  amnion  opened  there. 

If  the  labor  has  been  protracted,  it  will  not  infrequently  happen 
that  the  head  of  the  child  is  so  tightly  wedged  in  the 
pelvis  and  below  the  uterine  contraction  ring  that  strong 
traction  efforts  on  the  body  and  feet  fail  to  dislodge  it.  This  difficulty  has  been 
experienced  over  and  over  again  by  operators  for  the  past  hundred  years.  If 
the  head  does  not  yield  to  a  moderate  traction  made  upon  the  legs  and  body, 
then  the  feet  should  be  grasped  in  one  hand  just  above  the  ankles  while  the 
other  grasps  the  neck  and  shoulders,  guiding  the  traction  which  is  made  with 
both  hands  more  in  the  axis  of  the  superior  strait.  I  delivered  one  baby  by 
grasping  the  neck  and  shoulders  in  this  way  and  at  the  same  time  with  the  middle 
finger  of  the  same  hand  pushing  down  the  occiput,  which  lay  in  a  vertex  presen- 
tation, while  assisting  the  ffexion  and  traction  with  the  middle  finger  of  the  other 
hand  in  the  mouth.  Delay  at  this  point  endangers  the  life  of 
the  child,  and  if  the  head  is  not  at  once  freed  by  these  efforts  an  assistant 
must  insert  three  fingers  into  the  vagina  and  push  upward  on  the  head  at  the 
same  time  that  the  traction  is  being  made.  To  this  combined  vis  a  tergo  and 
vis  a  fronts  the  head  of  any  living  child  is  sure  to  yield. 

Clamping  the  Cord  . — In  order  to  shorten  the  time  as  much  as  possible 
between  making  the  uterine  incision  and  putting  in  the  sutures,  I  clamp  the  cord 
in  two  places  instead  of  tying  it  (see  Amer.  Jour,  of  Ohst.^  1891,  p.  538)  and  cut 
between  the  forceps,  freeing  the  child,  which  is  handed  over  to  the  nurse  or  to 
a  doctor  for  resuscitation,  if  asphyxiated. 

Controlling  the  Hemorrhage . — It  has  been  the  custom  to  prevent 
hemorrhage  during  the  operation  by  throwing  a  rubber  ligature  around  the 
lower  part  of  the  uterus  before  making  the  incision,  but  this  is  unnecessary,  as 
the  hemorrhage,  as  a  rule,  is  not  excessive  and  may  be  better  controlled  by  other 
means.  The  danger  of  the  ligature  is  that  it  predisposes  to  a  subsequent  atony 
of  the  uterus,  and  so  to  post-partum  hemorrhage. 

It  is  best  not  to  use  many  hemostatic  clamps,  which  crush  the  tissues  of  the 
uterine  wall.  If  the  incision  is  made  quickly  and  the  child  lifted  out  at  once, 
the  uterus  begins  to  contract  immediately,  diminishing  the  hemorrhage,  which 
may  also  be  temporarily  controlled  by  the  assistant  firmly 
grasping  the  neck  of  the  uterus  with  both  hands  down 
at  the  pelvic  brim.  Tlie  pulsations  of  the  uterine  arteries  can  be  dis- 
co 


420 


CESAREAN    SECTION. 


tinctly  felt  and  the  pressure  brought  to  bear  directly  upon  them  and  kept  up  as 
long  as  desired.  Tlie  contraction  of  a  flabby  uterus  may  be  excited  by  kneading. 
The  best  way  to  control  hemorrhage  permanently  is  by 
the  rapid  introduction  of  the  sutures  closing  the  uterine 
incision. 

Delivery  of  the  Placenta  and  Membranes . — As  soon  as  the 
child  is  delivered  and  the  uterus  begins  to  contract  lirndy,  the  placenta,  if  it  is 
not  already  freed  by  the  uterine  contraction,  is  delivered  by  grasping  it  in  the 
open  hand  and  drawing  the  lingers  together  and  twisting  it  until  it  is  freed  from 
its  base  and  comes  away  with  the  cord  and  membranes. 

Any  large  pieces  of  loose  decidual  membrane  left  in  the  uterus  should  be 
removed,  but  time  is  wasted  in  picking  off  little  pieces  from  the  walls.     I  do 

not  consider  it  necessary  to  use  iodoform 
powder  in  the  uterus,  as  has  been  sug- 
gested. 

The  Uterine  Suture.  — The 
uterus,  now  vigorously  contracted  and  much 
diminished  in  size,  is  lifted  out  of  the 
abdominal  incision  and  laid  on  a  thick 
pad  of  sterilized  ganze  while  the  deep  and 
superficial  sutures  are  being  introduced. 
If  the  abdominal  walls  are  thin  and  the* 
pelvis  narrow,  the  uterus  will  lie  so  close 
under  the  incision  that  it  will  not  be  neces- 
sary to  lift  it  out  to  pass  the  sutures. 

The  best  suture  material  for  the  uterus 
is  undoubtedly  fine  silk.  Catgut  should 
never  be  used,  because  it  is  liable  to  become 
absorbed  and  so  permit  the  incision  to  gape 
open. 

One  row  of  deep  interrupted  sutures 
from  top  to  bottom,  1  centimeter  apart, 
is  sufficient  to  close  the  uterine  wound 
thoroughly.  If  the  woman  has  been  long 
in  labor,  or  delivery  has  already  been  at- 
tempted by  means  of  the  forceps,  there  is 
always  an  increased  liability  to  sepsis,  and 
it  is  better  in  such  a  case  to  use  a  second  row  of  superficial  so-called  sero-serous 
sutures  covering  in  the  first  row.  Each  deep  suture  is  passed  by  a  needle  armed 
with  a  carrier  entering  5  to  8  millimeters  from  the  edge  of  the  incision  and 
brought  out  on  the  cut  surface,  on  a  line  between  the  muscularis  and  the 
decidua,  to  re-enter  and  emerge  at  the  corresponding  points  on  the  opposite 
side. 

Each  suture  is  best  tied  as  soon  as  passed,  bringing  the  wounded  surfaces 
snugly  together,  as  in  that  way  the  bleeding  is  stopped  the  quickest.     By  the 


Fig.  516. — Cesarean  Utekus  removed  Six 
Years  after  Operation. 
The  uterus  is  laid  open  on  its  anterior  sur- 
face, a  little  to  the  right  of  the  Cesarean  sear, 
which  is  seen  faintly  indicated  from  fundus 
down  to  cervical  region.  Tlie  transverse  cut 
shows  the  Cesarean  soar  extending  in  to  the 
uterine  mucosa.  There  is  no  thinning  of  the 
uterine  wall.     Natural  size. 


CONSERVATIVE    CESAREAN    OPERATION.  421 

time  all  the  deep  sutures  are  in  place,  if  there  is  oozing  between  any  of  them,  it 
may  be  checked  by  passing  a  few  half  deep  sutures  between,  and  tying  them 
tightly  enough  to  stop  the  flow ;  the  line  of  incision  now  has  a  slightly  blanched 
appearance.  The  superficial  sutures  are  next  passed  over  the  deep  ones,  catch- 
ing the  peritoneal  covering  of  the  uterus,  with  a  little  of  the  underlying  muscu- 
laris,  and  drawing  it  over  the  line  of  the  incision,  which  is  completely  hidden 
from  sight  when  they  are  all  tied.  In  this  way  a  good  barrier  is  formed  to  limit 
or  at  least  to  delay  the  advance  of  a  sej)tic  process  from  the  uterine  toward  the 
abdominal  cavity. 

Cleansing  the  Peritoneum , — If  the  peritoneum  has  been  consider- 
ably soiled  with  blood  and  amnion,  or  if  the  case  is  doubtfully  septic,  it  is  better 
to  flush  it  out  freely  with  a  normal  salt  solution  ;  otherwise  it  will  do  simply  to 
wipe  up  a  little  blood  and  fluid  and  lay  the  contracted  uterus  down  in  the  pelvis 
and  lower  abdomen,  so  that  the  cavity  of  the  body,  the  cervix,  and  the  vagina 
form  as  nearly  as  possible  a  straight  line. 

I  think  it  is  better  in  doubtful  cases  not  to  draw  the  omentum  down  over 
the  front  of  the  uterus  to  keep  it  away  from  the  abdominal  wall,  but  to  use  it  to 
protect  the  intestines.  Then  if  there  is  any  sepsis  it  is  more  likely  to  be  local- 
ized and  to  break  through  the  incision. 

Adhesions  are  almost  certain  to  be  formed  between  the  uterus  and  abdominal 
wall.  Mrs.  Reybold,  twice  operated  upon  by  Prof.  William  Gibson,  of  Phila- 
delphia, in  1835  and  1837,  died,  at  the  age  of  seventy-six  years,  in  1885,  and  at 
the  autopsy  the  fundus  of  the  uterus  was  found  adherent  to  the  upper  jDart  of 
the  abdominal  cicatrix  and  drawn  out,  like  a  dog's  tongue,  4^  inches  long  (P.  P. 
Harris). 

Closure  of  the  Abdominal  Wound . — The  abdominal  wound  is 
closed  by  fine  catgut  to  the  peritoneum,  by  silver  wire  tension  sutures  about  i 
centimeters  apart  and  catgut  in  between,  uniting  the  fascia  and  the  muscles,  and 
a  continuous  subcuticular  catgut  suture.  If  the  patient's  forces  are  flagging  and 
it  is  deemed  best  to  hasten  the  closure,  it  is  best  to  use  interrupted  silkworm-gut 
sutures,  passing  each  one  through  all  the  layers  of  the  wall,  except  the  perito- 
neum, which  is  closed  separately  with  catgut. 

The  Duration  of  the  Operation . — The  duration  of  the  operation, 
especially  that  part  during  which  the  uterus  lies  open  and  bleeding,  is  an  impor- 
tant feature  in  the  technique ;  if  the  operation  is  prolonged  much  over  an  hour, 
or  even  two  hours,  as  has  occurred,  then  none  but  the  strongest  patients  may 
be  expected  to  survive  the  shock,  and  in  the  case  of  those  who  do  survive, 
sepsis  will  more  readily  find  an  entrance  in  the  depressed  devitalized  condition. 
There  is  no  excuse  for  prolonging  the  operation  longer  than  thirty  or  forty 
minutes,  and  an  expeditious  operator  will  get  through  in  from  twenty  to 
twenty-five  minutes  or  even  less.  There  should  be  no  haste  at 
any  time,  but  every  step  should  follow  its  predecessor 
in  rapid  succession,  and  there  should  be  no  delays  due 
to  imperfect  preparation.  As  an  example  of  what  may  be  done 
with  proper  preparation  and  good  assistance,  I  quote  the   records  of   one  of 


422  CESAREAN   SECTION. 

my  operations  (E.  D,,  2412,  Jan.  14,  1891,  see  New  York  Medical  Journal, 
May  2,  1891). 

Incision  16  centimeters  {Q^  inches)  long,  begun  in  abdominal  wall. 

Fifteen  seconds  later  uterus  opened. 

Eight  hundred  to  1,000  cubic  centimeters  of  liquor  amnii  discharged. 

One  minute  from  the  commencement  the  child  delivered. 

Two  minutes  from  commencement  placenta  (non-prgevia)  delivered. 

Ten  minutes  from  commencement  the  uterine  wound  completely  closed  by 
seven  deep  and  eight  half  deep  silk  sutures  between  them. 

In  twenty-one  minutes  and  forty-five  seconds  from  the  beginning  the  abdo- 
men completely  closed  and  the  operation  over. 

Errors  in  Technique  . — Ei*rors  to  be  avoided  in  the  technique  are  : 

1.  The  attempt  to  preserve  a  uterus  which  is  jjrobably  septi6  and  would 
therefore  better  be  amputated. 

2.  The  use  of  any  antiseptic  solutions  whatever  in  the  abdominal  cavity. 

3.  Cutting  the  placenta  when  it  lies  under  the  incision. 

4.  Grasping  the  child  by  the  head  or  arm. 

5.  Wasting  time  in  picking  little  shreds  of  decidua  oif  the  uterus. 

6.  Constricting  the  neck  of  the  uterus  with  a  rubl)er  ligature. 

7.  The  use  of  catgut  for  the  deep  sutures  in  the  uterus. 

8.  The  use  of  a  continuous  suture  to  close  the  uterine  incision. 

9.  Drainage  of  the  abdomen. 

The  After  Care . — The  abdominal  wound  is  dressed  and  protected  as 
after  any  other  abdominal  section.  The  lochia  usually  flows  in  the  normal  man- 
ner, but  should  there  be  any  obstruction,  with  accumulation  of  clots  in  the 
vagina  or  uterus,  these  must  ])e  cleaned  out  and  the  tract  washed  out  with  slight 
force  so  as  not  to  make  any  pressure  upon  the  walls  of  the  uterus. 

My  first  case  in  Philadelphia  was  thoroughly  septic,  and  would  better  not 
have  been  treated  conservatively ;  owing  to  the  choked  condition  of  the  lower 
part  of  the  pelvis,  a  mass  of  fetid  clots  accumulated  in  the  lower  uterine  seg- 
ment, below  the  contraction  ring,  where  the  child's  head  had  laid  imbedded. 
After  a  few  days  the  vault  of  the  vagina  became  emphysematous,  crackling  on 
touch,  and  the  entire  cervix  sloughed  away  ;  subsequently  the  uterus  became 
emphysematous  and  the  lower  angle  of  the  abdominal  wound  opened,  form- 
ing an  abdomino-utero-vaginal  fistula,  Avhicli  persisted  into  the  next  preg- 
nancy. 

The  bowels  should  be  freely  moved  on  the  third  day  after  operation,  and 
the  urine  drawn  only  when  necessary,  and  then  with  the  utmost  care  to  avoid 
infection.  It  is  safer  immediately  after  the  operation  to  withdraw  the  iodoform 
gauze  from  the  vagina  and  use  a  vulvar  pad ;  every  time  fresh  gauze  or  cotton 
is  applied  under  the  vulva,  and  whenever  the  urine  is  drawn,  about  a  teaspoon- 
ful  of  iodoform  and  boric-acid  powder  (1  to  7)  should  be  dusted  well  into  the 
vaginal  outlet  as  a  protective  against  septic  invasion  from  without. 

The  baby  may  nurse  in  from  twelve  to  twenty-four  hours — as  soon  as 
the  effects  of  the  anesthetic  have  passed  off — and  may  continue  to  take  the 


THE    PORRO-CESAREAN    OPERATIOX.  423 

breast  as  under  ordinary  circumstances.  If  tlie  mother  is  quite  feeble  it  will  be 
well  to  keep  the  child  in  another  room  at  night. 

In  the  third  week  the  patient  may  sit  up  a  little,  and  in  another  week  or  ten 
days  she  may  go  about  her  room. 

The  Porro-Cesarean  Operation. — The  Cesarean  section  with  the  removal  of  the 
uterus,  the  I'orro-Cesarean  operation  (yDeW  amputatione  utero-ovaria  come  com- 
plemento  di  tagliu  ceaareo.  Ann.  Univ.  di  med.  e  chir.^  Milano,  1876),  showed 
itself  to  be  a  safer  procedure  than  the  conservative  Sanger-Cesarean  operation, 
at  a  time  when  all  abdominal  surgery  was  dangerous  and  infection  carried  off  a 
large  percentage  of  all  difficult  or  prolonged  operations.  The  removal  of  the 
uterus  with  its  pedicle  fastened  in  the  lower  angle  of  the  incision  was  safer  than 
its  preservation,  because  it  left  but  a  small  external  wound  surface,  while  in  the 
conservative  operation  the  whole  uterine  cavity  forming  one  big  wound  re- 
mained in  direct  relation  to  the  peritoneal  cavity  through  the  uterine  incision. 
Under  these  circumstances  the  removal  of  the  uterus  came  to  be  generally  rec- 
ommended as  the  best  plan  of  treatment  of  all  Cesarean  cases.  Surgical  prac- 
tice has  now  changed  so  nnich  that  the  two  operations  have  become  comple- 
mentary to  each  other  and  no  longer  rivals  in  the  same  field. 

The  Porro  operation  must  be  performed  in  cases  in  which 
some  morbid  element  makes  it  dangerous  to  keep  the  uterus  in  the  body. 

1.  Where  there  is  good  reason  to  anticipate  sepsis,  where,  for  example,  the 
patient  is  exhausted  by  a  protracted  labor,  and  where  manual  or  instrumental 
efforts  at  delivery  have  been  made  repeatedly  or  without  due  antiseptic  pre- 
cautions. 

2.  Where  there  is  cancer  of  the  cerWx  uteri. 

3.  Where  the  uterus  contains  myomatous  tumors  which  block  the  pelvis  or 
which  can  not  be  safely  removed  by  myomectomy. 

-i.  When  there  is  an  extensive  atresia  of  the  vagina. 

5.  When  there  are  bilateral  ovarian  tumors  and  no  sound  part  of  an  ovary 
can  be  found  and  left. 

6.  When  the  hemorrhage  from  the  placental  site  is  uncontrollable. 

The  number  of  suitable  cases  of  this  last  class,  however,  will  be  reduced  by 
avoiding  the  rubber  constricting  ligature,  and  probably  by  ligating  one  or  both 
uterine  arteries. 

The  great  obstetric  genius  of  Blnndell  in  the  early  part  of  this  century  so 
clearly  appreciated  the  advantages  of  a  complete  extirpation  of  the  uterus  that 
I  quote  his  language  as  a  contribution  to  the  history  of  the  subject : 

"  In  speculative  moments  I  have  sometimes  felt  inclined  to  persuade  my- 
self, the  dangers  of  the  Cesarean  operation  might,  perhaps,  be  considerably 
diminished  by  the  total  removal  of  the  uterus.  Eabbits  are  tender  animals, 
and,  bearing  many  fetuses,  have  wombs  after  delivery  of  great  proportion 
and  bulk,  indeed  nearly  large  enough  to  fill  the  hollow  of  the  hand.  If  the 
Cesarean  operation  be  performed  on  the  rabbit  in  the  ordinary  way,  unless 
I  am  much  mistaken,  it  will  be  found  that  the  animal  generally  perishes  in 
consequence. 


424:  CESAKEAN    SECTIOiq". 

"  But  in  four  rabbits  recently  delivered  I  made  an  opening  above  the  sym- 
physis pubis,  and  raising  the  wombs  from  the  abdomen,  I  elevated  them  above  the 
aperture,  the  animal  lying  in  the  recumbent  position,  stretched  out  at  full  length. 
This  accomplished,  I  took  a  ligature,  with  a  needle  on  its  center,  and  carrying 
the  pouit  from  behind  forward  I  passed  it  completely  through  the  vagina,  after- 
ward cutting  the  needle  away  in  this  manner  so  as  to  leave  two  strong  ligatures 
hanging  forth  from  the  aj)erture.  Having  applied  my  ligatures,  I  tied  one  on 
the  right  side  and  the  other  on  the  left  respectively  over  the  Fallopian  tube, 
drawing  the  threads  very  firmly,  so  as  completely  to  cut  off  all  communication  with 
the  vagina ;  and,  this  part  of  the  operation  carefully  performed,  I  took  a  knife 
and  completely  removed  the  wombs,  cutting  for  this  purpose  very  close  upon  the 
ligatures,  afterward  replacing  the  parts.  This  done,  after  closing  the  abdominal 
wound  by  suture  I  drew  forward  the  ligatures  through  the  wound  till  I  brought 
the  raw  surface  left  by  the  removal  of  the  wombs  in  contact  with  the  abdominal 
incision  internally.  By  means  of  the  ligature  the  wound  of  the  vagina  and  ad- 
jacent parts,  which  must  otherwise  have  been  of  great  extent,  being  drawn  to- 
gether into  a  very  narrow  compass,  became  not  broader  than  a  sixpence,  and  I 
trusted  that  this  might  promptly  contract  adhesions  with  the  inner  surface  of 
the  abdomen.  Beyond  my  hopes  the  operation  succeeded.  Of  the  four  rabbits, 
three  recovered,  the  fourth  dying  in  consequence  of  the  ligatures  slipping  from 
their  place. 

"  Experiments  of  this  kind  made  upon  different  animals  are  much  wanted, 
for  the  importance  of  the  subject  renders  multiplication  and  variety  desirable 
here.  Let  us  think  maturely  upon  facts  like  these.  In  performing  the  Cesa- 
rean delivery  on  the  human  body  perhaps  this  method  of  operating  may  here- 
after prove  an  eminent  and  valuable  improvement. 

"  Let  it  be  remembered  that  in  securing  the  vagina  and  removing  the  uterus 
we  are  substituting  a  wound  well  secured  and  of  smaller  extent  for  one  that  is 
larger  and  not  secured  by  ligature  at  all."  {The  Princijyles  and  Practice  of 
Olstetricy,  James  Blundell,  London,  1834,  pp.  5Y7,  578.) 

Three  Ways  of  Operating . — There  are  three  ways  of  doing  this 
operation,  differing  in  the  treatment  of  the  pedicle,  only  the  first  of 
which  can,  strictly  speaking,  be  called  a  Porro  operation  ; 

The  first  is  to  open  the  uterus  and  deliver  the  child,  and  then  to  ampu- 
tate the  uterus  and  fix  the  pedicle  in  the  lower  angle  of  the  abdominal 
wound. 

The  second  is  to  deliver  the  child,  amputate  the  uterus,  sew  up  the  stump, 
cover  it  with  a  peritoneal  flap,  and  drop  it  into  the  abdomen,  which  is  then 
closed. 

I  have  had  one  such  case  (K.  P.  S.,  8819,  Dec.  16,  1893)  where  the  Porro- 
Cesarean  section  was  made  necessary  by  a  large  myomatous  tumor  of  the  uterus 
entirely  blocking  the  pelvic  canal.  The  child  lived  for  several  days  and  the 
mother's  recovery  was  perfectly  satisfactory.     (See  Fig.  517.) 

The  third  is  to  remove  the  entire  uterus  (panhysterectomy),  opening  the 
vaginal  vault,  which  is  then  closed  by  suture  and  the  pedicle  dropped. 


THE    PORRO-CESAREAN    SECTION. 


425 


Operation . — I  would  in  all  cases  reject  the  first  method  of  hysterectomy 
and  select  either  the  second  or  the  third  as  more  in  keeping  with  advanced  sur- 
gical principles. 


Fig.  517. — Porro-Ce.sarean  Section  for  Fibroid  Uterus  at  Term. 
The  incision  throuj^h  which  the  cliild  was  extracted  is  seen  in  the  anterior  uterine  wall  above.     The  pla- 
centa was  not  removed,  and  the  cord  is  seen  projecting  from  the  cervical  end.    I'ath.  No.  180.    %  natural  size. 

When  the  pregnant  uterus  is  removed  for  myomata, 
persistent  hemorrhage,  or  a  vaginal  atresia,  it  is  better  to 
amputate  the  cervix,  close  it  by  suture,  and  drop  the 
pedicle  in  the  following  manner:  The  abdomen  is  opened  by  an  incision 
large  enough  to  bring  the  pregnant  uterus  outside.  To  prevent  the  intestines 
from  escaping  above,  pads  of  gauze  wrung  out  of  a  hot  normal  salt  solution  are 
laid  over  them  and  under  the  incision,  and  the  table  is  elevated  just  enough  to 
cause  them  to  tend  to  gravitate  upward.  The  child  is  then  delivered 
and  the  enucleation  proceeded  with.  It  is  not  necessary  to  extract  the  placenta 
and  the  meml)ranes.  The  ovarian  vessels  of  one  side  are  then  tied  near 
the  brim  of  the  pelvis  and  clamped  on  the  uterine  side  and  cut  between  clamp 
and  ligature. 

The  round  ligament  is  next  tied  about  3  centimeters  from  the  uterus 
and  clamped  close  to  it  and  cut  between  clamp  and  ligature. 

T  li  e  ovarian  vessels  and  round  ligament  of  the  opposite  side  are  tied 
and  cut  in  Hke  manner. 

The  vesical  p  e  r  i  t  o  n  e  u  m  is  next  freed  from  the  uterus,  from  round 
ligament  to  round  ligament,  and  the  bladder  with  its  peritoneum  pushed  well 
down  behind  the  symphysis. 


426  CESAREAN    SECTION. 

All  tliis  occupies  but  two  or  three  minutes,  and  the  uterus  now  remains  at- 
tached only  by  its  cervical  end,  well  lifted  up,  and  forming  a  pedicle  as  large  as 
two  or  three  lingers.  The  left  uterine  artery  is  distinctly  felt  pulsating,  and  is 
tied  by  passing  a  silk  ligature  around  it  with  a  needle  and  carrier.  The  uterus 
is  then  amputated  about  1"5  centimeter  (f  inch)  above  the  ligature  and  the  ojjpo- 
site  right  uterine  artery  clamped  with  forceps,  before  it  is  divided,  at  a  point  well 
above  the  pedicle.  The  uterine  vessels  on  the  right  side  may  also  be  equally 
well  ligated  before  amputating  the  cervix. 

After  the  removal  of  the  uterus  in  this  way  a  ligature  is  applied  to  the  right 
uterine  artery.  The  cervical  canal  is  carefully  wiped  out,  and  its  anterior  and 
posterior  lips  united  by  from  six  to  eight  catgut  sutures,  tied  tight  enough  to 
check  any  oozing.  It  is  a  good,  precaution  to  tie  all  the  important  arteries  a 
second  time  with  catgut.  The  anterior  layers  of  the  broad  ligament  and  the 
vesical  peritoneum  are  now  drawn  over  and  attached  to  the  posterior  layers  and 
the  cervical  stump  by  a  continuous  catgut  ligature  extending  from  the  pelvic 
brim  of  one  side  to  the  brim  of  the  other  side,  completely  hiding  from  view  the 
entire  field  of  the  operation.  A  loose  iodoform  gauze  pack  is  then  placed  in 
the  vagina  and  left  there  for  five  or  six  days. 

The  third  method,  that  of  total  extirpation  of  the  uterus,  is  per- 
formed for  cancer  of  the  cervix  and  for  a  septic  uterus,  where  there  have  been 
protracted  attempts  at  delivery  and  the  patient  is  febrile. 

There  should  be  a  thorough  cleansing  of  the  vagina  first,  and  as  much  of  the 
cancerous  material  as  can  be  removed  without  provoking  a  serious  hemorrhage 
should  be  taken  away.     The  vagina  is  then  loosely  packed  with  iodoform  gauze. 

The  uterus  is  delivered  through  the  incision,  the  ovarian  vessels  and  round 
ligaments  tied  off,  and  the  vesical  peritoneum  pushed  down  as  just  described. 

The  uterus  is  now  opened  and  the  child  delivered,  after  which  the  uterus  is 
at  once  tightly  wrapped  in  towels,  to  squeeze  the  edges  of  the  incision  well 
together,  as  well  as  to  give  a  good  hold  and  to  protect  the  surgeon's  hands  and 
the  patient's  abdomen  from  being  soiled. 

Hemorrhage  must  be  prevented  during  this  more  prolonged  operation  by 
tying  a  rubber  ligature  tightly  around  the  cervix.  The  important  object  of 
the  next  step  in  the  operation  is  to  enucleate  the  whole  lower  segment  of  the 
uterus  with  any  infected  glands  and  with  as  much  of  the  surrounding  cellular 
tissue  as  possible,  without  injuring  either  of  the  ureters.  This  has  been  so 
carefully  described  in  Chapter  XXX,  on  panhysterectomy  for  cervical  cancer, 
that  I  shall  not  repeat  here  more  than  the  bare  statement  that  the  uterine  artery 
is  ligated  close  to  its  origin  from  the  internal  iliac,  and  a  painstaking  dissection 
is  made  from  this  point  in  toward  the  uterus  on  each  side,  detaching  the  cellular 
tissue  and  the  glands,  which  are  finally  removed  with  the  cervix.  The  only 
safeguard  against  injuring  a  ureter  is  to  l)e  constantly  aware  of  its  exact  posi- 
tion, either  by  sight  or  touch,  and  under  no  circumstances  should  mass  ligatures 
be  used  to  control  the  vessels  in  the  tissues  near  the  vaginal  vault. 

Having  in  this  way  freed  the  uterus  on  all  sides  down  to  its  vaginal  attach- 
ment before  opening  the  vagina,  it  is  important  to  provide  for  the  careful  pro- 


CESAREAN    SECTION    ON    THE    DEAD.  427 

tection  of  the  pelvic  peritoneum  by  packing  in  gauze  on  all  sides,  so  that  any 
escaping  secretions  will  be  at  once  taken  up.  The  uterus  is  now  drawn  up  and 
the  position  of  the  vagina  found  by  palpation,  by  seeing  the  longitudinal  muscu- 
lar fibers,  and  by  the  clear  tympanitic  note  which  it  yields  on  percussion. 

As  soon  as  the  vagina  is  cut  into  anteriorly  more  iodoform  gauze  must  be 
stuffed  into  it  to  take  up  any  moisture  and  to  limit  the  chances  of  contamina- 
tion. Freely  bleeding  points  in  the  cut  edges  must  be  caught  and  held  by  for- 
ceps until  controlled  by  sutures. 

The  anterior  and  posterior  vaginal  walls  are  now  brought  together  with  in- 
terrupted catgut  sutures  and  the  anterior  peritoneal  folds  united  to  the  posterior, 
as  described  in  the  preceding  method,  completely  hiding  away  the  whole  field  of 
operation.  I  think  it  is  best  in  septic  and  cancerous  cases  to  lay  a  small  gauze 
drain  under  the  pelvic  peritoneum,  and  to  bring  it  out  into  the  vaginal  tract  as 
a  safeguard  against  any  infection  lodged  in  the  cellular  tissue.  The  drain  may 
be  removed  in  from  four  to  six  days.  The  vagina  must  also  be  tilled  after  the 
operation  with  a  loose  pack  of  washed-out  iodoform  gauze. 

The  further  after  care  does  not  differ  in  any  important  particular  from  that 
of  an  ordinary  celiotomy. 

Cesarean  Section  on  the  Dead. — It  is  forbidden  in  Austria  to  bury  a  woman 
dying  in  the  second  half  of  pregnancy  without  first  performing  Cesarean  section 
with  all  the  care  and  technical  skill  used  in  operating  during  life,  in  hoj^es  of 
either  saving  the  child,  or  at  least  of  baptizing  it. 

Such  an  operation  succeeds  only  in  extremely  rare  cases  in  spite  of  the  in- 
stances reported  in  the  older  literature. 

Cesarean  section  in  agoni a — that  is  to  say,  just  before  life  is  ex- 
tinct— although  it  increases  the  chances  of  the  child,  offers  at  best  but  a  forlorn 
hope,  as  the  extremely  reduced  condition  of  the  mother  for  some  time  before 
death  generally  interferes  with  the  proper  oxygenation  of  the  fetal  blood  and  so 
causes  its  earlier  death. 

The  wiser  plan  would  be,  in  event  of  the  prospect  of  the  certain  death  of  the 
mother  in  the  near  future,  to  induce  labor  a  few  days  before  the  anticipated 
event,  or  even  to  perform  Cesarean  section  at  her  urgent  request.  The  great 
difficulty  in  the  way  in  such  a  case  is  the  manifest  liability  to  error  in  estimating 
how  long  the  patient  still  has  to  live. 

Successful  cases  of  Cesarean  section  in  agonia  saving  the  child's  life  have 
been  recorded  recently  by  Runge  for  brain  tumor,  by  Frank  for  general  l)urns, 
by  Fehling  for  basilar  meningitis,  by  Sommerbrodt  for  fibro-sarcoma  cerebri,  by 
Schweiger  for  gliosarcoma  cerebri,  and  by  Hays  for  cerebral  apoplexy  (see 
Schauta,  Lehrh.  der  gef«immt  Gyn.,  1S96,  p.  1050).  Dr.  E.  P.  Davis,  of  Phila- 
delphia, delivered  a  living  child  immediately  after  the  mother  had  died  of 
eclampsia  (see  Ifed.  News^  Feb.  1,  1S96).  As,  however,  Schauta  justly  says, 
the  improvement  of  the  methods  of  artificial  delivery  by  the  vagina,  the  rapid 
dilatation  and  incisions  of  the  cervix  and  colpeurysis  of  the  vagina,  with  inci- 
sions of  the  perineum  associated  with  turning,  has  still  further  limited  the  field 
for  this  rare  operation. 


CHAPTEE  XXXIV. 

EXTRA-UTERINE   PREGNANCY. 

1.  Definition. 

2.  Causes :  1.  Obstacles  within  the  lumen  of  the  tube  by  which  its  caliber  is  diminished.    2.  Dis- 

eases of  the  tube  itself  and  peculiarities  in  its  anatomy  or  form.  3.  Factors  acting  exter- 
nally to  the  tube  by  which  its  lumen  is  encroached  upon  or  obliterated.  In  particular  the 
causes  mav  be  classified  as:  a.  Tubal  polyps,  h.  Atresia  of  one  tube  with  external  migra- 
tion of  the  fertilized  ovum  from  the  opposite  side.  c.  Persistence  of  a  fetal  type  of  tube. 
d.  Diverticula  from  the  lumen  of  the  tube.  e.  Torsion  of  the  tube.  /.  Catarrhal  and  puru- 
lent salpingitis,  g.  Myoma  uteri.  /;.  Peritoneal  bands  and  adhesions  compressing  the  tube. 
i.  Cervico-abdominal  fistuhie  after  hysterectomy. 

3.  Forms  of  extra-uterine  pregnancy — Primary :  Interstitial ;  tubal ;  ovarian.    Secondary :  Intra- 

uterine ;  abdominal;  intraligamentary.  Primary  tubal  may  terminate  as  a  mole;  tubal 
abortion;  tubo-abdominal ;  tubo-ovarian  ;  rupture  into  abdomen  ;  intraligamentary. 

4.  Criteria  of  extra-uterine  pregnancy:   1.   Of  a  tubal  pregnancy.     2.   Of  an  intraligamentary 

tubal  pregnancy.     3.  Of  an  interstitial  tubal  pregnancy.     4.  Of  an  ovarian  pregnancy. 

5.  Clinical  history  of  an  extra-uterine  pregnancy  without  operation  :  1.  Tubal  abortion.    2.  Tubal 

mole.     3.  Interstitial  pregnancy.     4.  Categorical  statement  of  final  results. 

6.  Multiple  pregnancy. 

7.  Repeated  extra-uterine  pregnancies. 

8.  Diagnosis  :  1.  In  unruptured  cases.    2.  In  ruptured  cases. 

9.  Mortality :  Unruptured  sac.     Ruptured  sac. 

10.  Treatment:  Vaginal  incision  and  drainage.  Intraligamentary  and  pseudo-intraligamentary 
extra-uterine  pregnancy.  Operative  treatment  of  advanced  extra-uterine  pregnancy. 
Treatment  of  an  interstitial  pregnancy.     Pregnancy  in  a  rudimentary  horn  of  the  uterus. 

When  the  fertilized  ovum  is  arrested  at  any  point  between  the  Graafian 
folhcle  and  the  uterine  cavity  and  there  undergoes  development,  vs^e  designate 
the  condition  as  an   extra- uterine  or  an   ectopic   pregnancy. 

The  ovum  may  be  arrested  within  the  ovary  or  in  any  portion  of  the  uterine 
tube  from  its  fimbriated  extremity  to  its  interstitial  portion  inclusive. 

Extra-uterine  pregnancy  is  primarily  almost  always  situated  in  the  tube,  but 
may  become  tubo-ovarian,  abdominal,  or  intraligamentous,  or  even  uterine  in  the 
further  course  of  its  development.  Ovarian  pregnancy  is  one  of  the  greatest 
gynecological  rarities. 

Causation. — The  factors  which  lead  to  the  arrest  and  development  of  the 
fertilized  ovum  within  the  oviduct  are  usually  of  a  mechanical  nature,  by  which 
the  downward  progress  of  the  ovum  from  the  Graafian  follicle  to  the  uterine 
cavity  is  impeded. 

Such  causes  may  be  classified  under  three  heads : 

1.  Obstacles  within  the  lumen  of  the  tube,  by  which  its  caliber  is  diminished. 

2.  Diseases  of  the  tubal  walls  and  peculiarities  in  its  anatomy  or  form. 

3.  Factors  acting  externally  to  the  tube,  by  which  its  lumen  is  encroached 
upon  or  obliterated. 

428 


FlO.    518. — EXTUA-UTERINE    PREGNANCY    GONE    SOME    SiX    OR    ElOUT    MoNTlIS    BEYOND    TeRM  ;    FaI.SE    LaBOR 

AND  Death  of  the  Child. 

The  fetus,  placenta,  and  niemV>ranes  were  all  removed  tojretlier.  Note  the  sodden  collapsed  body  and  the 
maceration  of  the  skin  whicli  is  peeliui;  otF,  ]iarticvilarly  over  the  body.  Operation.  Dcatli  from  streptococ- 
cus infection.     Measurement  from  head  to  rump  ^0  centimeters,     rhoto.,  625. 


CAUSATION.  429 

In  particular  the  causes  may  be  classiiied  as : 

(a)  Tubal  polypi. 

(b)  Atresia  of  one  tube  with  external  migration  of  the  fertilized  ovum  or  the 
spermatozoa  from  the  opposite  side. 

(c)  Persistence  of  a  fetal  type  of  uterine  tul)e  (Freund). 

(d)  Diverticula  from  the  lumen  of  the  tube  (Landau  and  Williams). 

(e)  Torsion  of  the  tube. 

(f)  Catarrhal  and  purulent  salpingitis  (Tait,  Orthmann). 

(g)  Myoma  uteri  (Leopold). 

(h)  Peritoneal  bands  and  adhesions,  compressing  the  tube. 

(i)  Cervico-abdominal  fistula  after  hysterectomy  (Koeberle  and  Lecluyse), 
and  perhaps  I  might  add  peculiarities  of  the  ovum,  such  as  excessive  size,  due 
to  twin  pregnancy. 

The  earlier  waiters  upon  this  subject  were  greatly  hampered  in  studying  the 
causation  of  extra-uterine  pregnancy  by  erroneous  views  as  to  the  place  of  meet- 
ing between  the  ovum  and  the  spermatozoa ;  it  was  formerly  supposed  that 
fertilization  normally  occurred  in  the  upper  part  of  the  uterus,  and  that  this 
was  brought  about  by  the  antagonistic  action  of  the  cilia  of  the  uterine  and  tubal 
mucosae ;  it  was  generally  believed  that  the  current  produced  by  the  cilia  of 
the  uterus  was  directed  upward  toward  the  fundus,  while  the  tubal  current  was 
directed  downward,  and  that  the  two  met  and  practically  neutralized  each  other 
at  the  upper  part  of  the  uterine  cavity  (Tait,  Wyder). 

Recent  observations  by  Hofmeier  have,  however,  shown  that  these  views  are 
erroneous,  and  that  the  current  produced  by  the  uterine  cilia  in  women  is  in 
exactly  the  same  direction  as  the  tubal  current — namely,  from  above  down- 
ward— so  that  the  action  of  the  cilia  tends  to  assist  the  ovum  in  its  downward 
progress,  and  to  interfere  more  or  less  with  the  upward  passage  of  the  sperma- 
toza,  so  that  if  they  were  not  endowed  with  motility,  it  is  probable  that  concep- 
tion would  never  occur. 

Observations  upon  animals,  since  the  time  of  Bischoff,  have  shown  that  the 
spermatozoa  normally  make  their  way  up  into  the  tube,  and  may  even  be  seen 
swimming  in  the  peritoneal  fluid  on  the  surface  of  the  ovary,  where  they  lie  in 
wait  for  the  ovum. 

It  has  likewise  l)een  shown  that  spermatozoa  may  retain  their  vitality  for  a 
considerable  length  of  time  within  the  tube ;  they  have  been  found,  for  exam- 
ple, in  the  female  bat  six  months  after  the  last  copulation. 

These  facts  would  tend  to  show  that  fertilization,  in  the  lower  animals  at 
least,  occurs  in  the  tube,  most  probably  in  its  upper  part,  and  that  the  fertilized 
ovum  is  carried  to  the  uterus  by  the  action  of  the  tubal  cilia. 

The  observation  by  Duhrssen  of  spermatozoa  in  the  normal  uterine  tube  of  a 
woman  three  and  a  half  weeks  after  the  last  copulation  tend  to  show  that  the 
views  just  adduced  may  likewise  apply  to  the  human  female. 

"We  therefore  believe  that  e  x  t  r  a  -  u  t  e r i  n  e  pregnancy  is  simply 
due  to  some  interference  with  the  normal  downward  pas- 
sage of  the  fertilized  ovum  through  the  tube. 


430  EXTRA-UTERINE    PREGNANCY. 

Tubal  Polyp . — The  explanation  wliicli  appealed  most  strongly  to  the 
early  investigators  was  that  the  ovum  was  prevented  from  entering  the  uterus 
by  some  obstruction  in  the  tube,  such  as  a  polyp,  which  partially  occluded  its 
lumen.  But  it  is  apparent,  from  the  few  instances  in  which  such  an  obstruction 
has  been  found  in  the  large  numl^er  of  carefully  examined  cases,  which  have  been 
reported  during  the  last  few  years,  that  this  is  a  comparatively  infrequent  cause. 

Atresic  Tube . — T  he  external  migration  of  the  fertilized 
ovum  from  one  side,  which  is  patulous,  to  the  opposite  tube,  whose  lumen  is 
occluded  in  some  part  of  its  course,  offers  a  satisfactory  explanation  for  a  consid- 
erable number  of  cases. 

A  case  operated  upon  by  Dr.  H.  C.  Coe  and  described  by  Dr.  J.  W.  Williams 
affords  most  convincing  proof  of  this  mode  of  origin.  The  left  uterine  tube  was 
the  seat  of  two  extra-uterine  pregnancies.  At  its  uterine  end  was  a  small  sac 
containing  the  skeleton  and  calcified  remains  of  a  fetus,  which  completely  oc- 
cluded that  portion  of  the  tube,  and  from  the  satisfactory  history  obtained  clearly 
represented  the  remains  of  an  extra-uterine  pregnancy  which  had  occurred 
twelve  years  previously,  while  the  lateral  end  of  the  tube  contained  the  placenta 
and  the  membranes  of  a  four  months'  pregnancy  which  had  ruptured,  allowing 
the  escape  of  the  fetus  into  the  abdominal  cavity,  where  it  was  found  alive  at 
the  operation.  The  left  ovary  was  small  and  atrophic  and  presented  absolutely 
no  sign  of  a  recent  corpus  luteum.  The  right  tube  presented  signs  of  peri-sal- 
pingitis  and  endo-salpingitis ;  but  its  fimbriated  extremity  was  patent,  and  the 
right  ovary  contained  a  corpus  luteum,  corresponding  in  size  to  the  duration 
of  the  pregnancy. 

It  is  apparent  that  the  spermatozoa  could  not  in  this  case  have  passed  the 
occluded  portion  of  the  tube,  where  the  lithopedion  was  situated ;  and  the 
absence  of  a  corpus  luteum  on  that  side  is  conclusive  evidence  that  the  ovum 
from  which  the  second  recent  pregnancy  was  developed  must  have  come  from 
the  opposite  side,  where  there  was  a  distinct  corpus  luteum ;  the  only  plausible 
explanation,  therefore,  is  that  the  spermatozoa  passed  through  the  right  tube, 
fertilized  an  ovum  from  the  right  ovary,  which  then  migrated  to  the  left  tube, 
passed  through  its  patent  fiml)riated  extremity,  and  made  its  way  onward  until 
arrested  by  the  lithopedion,  where  it  developed. 

It  is  also  theoretically  possible  for  spermatozoa  to  migrate  from  the  normal 
to  the  diseased  side,  where  they  may  fertilize  an  ovum,  which  may  pass  down 
the  diseased  tube  to  the  point  of  atresia  and  there  develop. 

External  migration  of  the  ovum  occurs  comparatively  fre- 
quently in  extra-uterine  pregnancy ;  Dr.  Williams  has  been  able  to  demonstrate 
it  in  five  out  of  thirty  cases,  of  which  he  has  accurate  pathological  records.  In 
all  of  them  the  fimbriated  extremity  of  one  tube  was  completely  occluded  by 
old  inflammatory  processes,  or  the  tube  was  converted  into  a  hydrosalpinx,  while 
the  other  tube  was  the  seat  of  the  pregnancy,  and  presented  a  patent  fimbriated 
extremity.  In  each  case  the  ovary  on  the  pregnant  side  presented  absolutely  no 
evidence  of  a  corpus  luteum,  while  the  ovary  corresponding  to  the  occluded  tube 
contained  a  typical  corpus  luteum  of  pregnancy. 


CAUSATIOX.  431 

Although  at  first  sight  such  a  "  migration  "  (?)  of  the  ovum  appears  difiieult 
to  explain,  my  observations  at  the  operating  table  lead  me  to  believe  that  it  may 
be  of  tolerably  frequent  occurrence  under  ordinary  conditions,  for  I  have  repeat- 
edly found  both  tubes  and  ovaries  lying  low  down  behind  the  uterus,  with  the 
fimbriated  extremity  of  the  right  tube  in  contact  with 
the    lej^t    ovary,    and    vice    versa. 

In  one  instance  I  removed  the  diseased  tube  on  one  side  and  the  diseased 
ovary  from  the  opposite  side,  leaving  behind  only  the  right  tube  and  the  left 
ovary.  Pregnancy  occurred  within  a  short  time  and  the  patient  was  delivered 
at  term;  at  a  later  date  an  extra-uterine  pregnancy  occurred  and  I  was  obliged 
to  remove  the  remaining  tube. 

Persistence  of  a  Fetal  Type  of  the  Tube. — The  labors  of  W. 
A.  Freund  {Samml.  Min.  Vortrdge,  1886,  Xo.  323)  have  shown  that  a  congenital 
malformation  of  the  tube  has  much  to  do  with  the  production  of  extra-uterine 
pregnancy,  for  the  fetal  tube  has  a  narrow  lumen  and  is  markedly  convoluted, 
thus  tending,  both  by  its  narrowed  caliber  as  well  as  by  the  greater  distance 
which  the  growing  ovum  has  to  travel  to  reach  the  uterus,  to  bring  about  re- 
tention mthin  the  tube. 

Diverticula . — Diverticula  from  the  lumen  of  the  tube  are  probably 
among  the  most  frequent  causes.  Attention  was  directed  to  this  condition 
almost  simultaneously  by  Landau  and  Rheinstein  {Arch.  f.  Gyn..,  Bd.  xxxix,  p. 
273)  and  by  J.  W.  Williams  {Amer.  Jour.  Med.  Set.,  Oct.,  1891). 


Fio.  519. — TvBAL  Diverticula  forming  Two  Eounded  Eminences  on  the  Upper  Rorper  of  the  Am- 
pulla. 

Tlie  neritoncum  was  intact,  while  the  mucosa  of  the  tube  was  cleft  all  the  way  through,  as  tliough  tlie 
attempt  nud  been  made  to  form  two  additional  tubal  orifices.     Natural  size. 

These  diverticula  are  simply  little  offshoots  from  the  lumen  of  the  tube, 
which  extend  into  its  muscular  wall,  penetrate  it  for  a  greater  or  lesser  distance, 
frequently  running  parallel  to  the  tubal  lumen,  and  eventually  end  blindly  as  a 
mere  cid-(1c-f«(c  (see  Fig.  510).  Sliould  a  fertilized  ovum  make  its  way  into  such 
a  diverticulum,  it  would  be  carried  to  its  blind  end  by  the  cilia,  there  be  arrested, 
and  undergo  further  development.  It  is  apparent  that  rupture  will  occur  earlier 
in  these  cases  than  when  the  pregnancy  occurs  earlier  in  tlie  main  lumen  of  the 
tube,  fur  in  the  former  case  the  pregnancy  is  separated  from  the  surface  of  the 


432  EXTRA-UTERINE    PREGXANCY. 

tube  only  by  a  fraction  of  tlie  thickness  of  its  wall,  instead  of  by  its  entire  thick- 
ness, as  when  it  develops  in  the  main  lumen. 

It  is  impossible  to  make  absolute  statements  as  to  the  frequency  of  this  con- 
dition until  serial  sections  of  the  entire  tube  have  been  cut  in  a  large  number  of 
cases,  which  has  not  yet  been  done;  but  it  probably  occurs  frequently;  Dr. 
Williams  has  been  able  to  demonstrate  this  mode  of  development  in  four  and 
possibly  five  cases  out  of  thirty  specimens  which  he  has  examined. 

Accessory  Ostia . — The  accessory  tubal  ostia  (Kossmann,  Zeit.  f.  Geh. 
u.  Gyn.,  Bd.  xxvii,  p.  266)  act  very  much  as  diverticula  by  breaking  the  conti- 
nuity of  the  walls  of  the  tube,  and  thus  interfering  with  the  normal  passage  of 
the  ovum  toward  the  uterus.  This  condition  explains  only  the  extra-uterine 
pregnancies,  which  occur  in  the  ampullar  portion  of  the  tube,  where  accessory 
ostia  are  usually  found. 

Inflammatory  Affections. — Orthmann  and  Tait  believe  that  in- 
flammatory aifections  of  the  tube  play  a  most  important  part  in  the  causation  of 
extra-uterine  pregnancy.     Tait  thinks  that  catarrhal  salpingitis  leads  to  the  pro- 


Fio.  520.— Triple  Tubal  Ostia.     March  8,  1894.     No.  202.     Natural  Size. 

duction  of  an  extra-uterine  pregnancy  by  the  destruction  of  the  ciliated  epithe- 
lium ;  this  interferes  with  the  normal  downward  current  of  the  tubal  secretion 
and  allows  the  entrance  of  spermatozoa,  which  then  fertilize  the  ovum  within 
the  tube,  where  it  undergoes  its  further  development. 

The  fallacy  of  this  conception  has  been  demonstrated  by  A.  Martin,  and  it  is 
generally  admitted  that  spermatozoa  readily  make  their  way  up  the  tube,  in 
spite  of  the  downward  current  produced  by  the  cilia,  and  that  fertilization 
nearly  always  occurs  in  the  tube ;  indeed,  the  careful  examination  of  inflamed 
tubes  shows  that  the  cilia  are  rarely  destroyed,  even  in  well-marked  cases  of 
pyosalpinx,  and  are  perfectly  preserved  in  cases  of  catarrhal  salpingitis.  When 
we  add  to  this  the  fact  that  cilia  are  readily  demonstrated  in  nearly  every  case 
of  tubal  pregnancy  which  has  been  examined  by  Dr.  Williams  or  my  assistants, 
it  is  apparent  that  some  other  cause  than  the  destruction  of  cilia  must  be  invoked 
to  explain  the  occurrence. 


CLASSIFICATION".  433 

It  is  more  probable  that  the  tLickening  of  the  tubal  walls,  which  frequently 
accompanies  marked  salpingitis,  facilitates  the  arrest  of  the  fertihzed  ovum 
somewhere  within  the  tube  by  interfering  with  its  peristaltic  movements  and 
by  choking  the  luinen. 

Purulent  Salpingitis  on  the  Affected  Side . — In  three  cases 
out  of  thirty  Williams  found  that  the  pregnant  tube  was  the  seat  of  a 
purulent  salpingitis,  and  in  one  other  case  there  was  a  follicular  sal- 
j)ingitis ;  but  he  hesitates  to  state  whether  the  tubal  disease  played  a  part  in  the 
production  of  the  extra-uterine  pregnancy,  or  was  simply  an  accidental  com- 
plication. 

Pelvic  Peritonitis . — Peritoneal  adhesions,  binding  down  the  tube  and 
restraining  its  movement,  may  not  infrequently  play  a  part  in  the  production  of 
an  extra- uterine  jDregnancy.  We  frequently  find  at  operation  evidence  of  old 
inflammatory  disease  on  both  sides,  and  the  history  of  the  patient  often  points 
quite  clearly  to  repeated  attacks  of  pelvic  peritonitis.  In 
addition  to  this,  the  fact  is  most  suggestive  that  extra-uterine  pregnancy  fre- 
quently occurs  in  women  who  have  long  been  sterile. 

A  dense  adhesion  stretching  across  the  tube  so  as  to  constrict  its  lumen  may 
likewise  be  a  cause  in  rare  instances.  In  one  of  my  abdominal  operations  I 
found  the  left  tube  so  constricted  by  vesical  adhesions  passing  across  its  isthmus 
that  it  was  nearly  severed,  and  its  lumen  almost  entirely  occluded.  A  twist 
in  the  tube,  practically  obliterating  its  lumen,  with  the 
pregnancy  in  its  distal  side,  was  the  apparent  cause  in  one  of  Williams's 
thirty  cases. 

Myoma  Uteri . — A  myoma  at  the  coruu  uteri  (Leopold)  may  so  distort 
and  compress  the  lumen  of  the  tube  and  interfere  with  its  functional  activity 
as  to  offer  a  marked  obstacle  to  the  downward  passage  of  the  fertilized  ovum 
toward  the  uterus. 

The  cases  of  Koeberle  and  of  Lecluyse  {Bull,  de  VAcad.  de  Tried,  de  Belge^ 
18G9)  may  be  finally  mentioned  among  the  rare  and  remarkable  cases  in  the 
annals  of  extra-uterine  pregnancy. 

Here,  in  spite  of  the  removal  of  the  uterus,  the  spermatozoa  passed  upward 
into  the  abdominal  cavity  through  a  cervical  fistula,  where  they  fertilized  an 
ovum  somewhere  in  the  pelvis,  presumably  in  one  of  the  tubes. 

Classification. — -A  natural  classification  of  the  various  forms  of  extra-uterine 
pregnancy  is  one  based  upon  the  original  point  of  implantation  of  the  fertilized 
ovum.  When  it  remains  and  develops  where  it  was  first  arrested,  we  designate 
it  as  primary  extra-uterine  pregnancy ;  upon  changing  its  position  by  rupture 
or  further  development  it  is  designated  as  secondary. 

The  primary  tubal  forms  are,  according  to  the  site  of  the  ovum,  the  inter- 
stitial, the  isthmial,  and  the  ampullar ;  J.  C.  Webster  further  distinguishes  an 
infundibular  form,  which  becomes  secondarily  tubo-ovarian  or  tubo-abdominal. 
The  tubo-ovarian  form  may  develop  in  an  ovarian  tube — that  is,  one  whose  fim- 
briated extremity  is  glued  down  by  adhesions  to  a  limited  portion  of  the  ovary 
{Hennig). 

70 


Tubal may  become  -| 


434  EXTRA-UTERINE    PREGNANCY. 

The  table  here  giv^en  shows  the  changes  which  each  of  the  primary  forms 
may  undergo : 

Tahle  of  Forms  of  Extra-uterine  Pregnancy. 

PRIMARY    FORMS.  SECONDARY    FORMS. 

r  Intra-uterine. 

Interstitial may  become  -|  Abdominal  (fetus  dies). 

I  Intraligamentary  (fetus  dies). 

Mole  (fetus  dies). 

Abortion  (fetus  dies). 

Tubo-abdominal. 

Tubo-ovarian. 

Abdominal. 

Intraligamentary  (fetus  dies). 
Ovarian may  become      Abdominal  (fetus  dies). 

As  I  have  already  stated,  ovarian  pregnancy  is  the  rarest  of  all  forms  (see 
Leopold,  ArcJi.  f  Gyn.,  Bd.  xix,  p.  210),  and  the  interstitial  form  is  of  infre- 
quent occurrence.  Martin  found  one  of  the  latter  in  seventy-seven  cases.  I 
have  never  observed  an  example  of  either.  Almost  all  cases  of  tubal  j>reg- 
nancy  occur  either  in  the  isthmus  or  ampulla  of  the  tube,  and  rarely  at  its  fim- 
briated end.  Zweifel  distinguishes  (see  Arch.f.  Gyn.,  Bd.  xli)  a  further  form 
in  which  the  ovum  does  not  enter  the  lumen  of  the  tube,  but  becomes  attached 
to  the  tubo-ovarian  fimbria  and  there  develops,  in  his  case  it  was  a  pregnancy 
of  about  five  months ;  this  might  in  a  certain  sense  even  be  denominated  a 
primary  abdominal  pregnancy.  In  rare  instances  a  tubal  pregnancy  may  de- 
velop and  reach  full  term  without  rupture,  but  more  frequently  the  sac  ruptures 
into  the  abdominal  cavity  or  within  the  folds  of  the  broad  ligament,  or  through 
the  fimbriated  end  of  the  tube.  The  primary  abdominal  forms 
have  disappeared  from  our  nomenclature  since  Worth  has  shown  that  the 
classical  cases  reckoned  as  such  were  all  tubal  in  their  origin. 

A.  Martin  classifies  seventy-seven  cases  of  extra-uterine  pregnancy  coming 
under  his  personal  observation,  according  to  the  seat  of  the  ovum,  as : 

Ampullar 48  times. 

Isthmial 8     " 

Interstitial 1     " 

Intraligamentary 7     " 

Tubo-ovarian 6     " 

Tu1)o-al)(lominal ?>     " 

Ovarian 1     " 

Undetermined 3     " 

Judging  by  my  own  experience,  I  should  say  that  rupture  within  the  folds 
of  the  broad  ligament,  with  intraligamentary  or  subperitoneo-pelvic  develop- 
ment, occurs  but  rarely ;  I  have  observed  it  only  twice  in  twenty-three  cases  of 
extra-uterine  pregnancy  in  one  thousand  celiotomies. 


CLASSIFICATIOlSr.  435 

In  several  old  pelvic  inflammatory  cases  1  have  found  the  tube  and  ovary  s  o 
enveloped  by  adhesions,  which  presented  a  smooth  surface  toward  the 
abdominal  cavity,  that  the  tubal  pregnancy  appeared  to  lie  be- 
neath the  peritoneum.  Such  cases  may  be  well  designated  as  p  s  e  u  d  o  - 
i  n  t  r  a  1  i  g  a  lu  e  n  t  a  r  y ,  and  may  be  differentiated  from  the  true  intraligamen- 
tary  form  by  the  fact  that  a  little  patience  enables  one  to  separate  the  adhesions 
posteriorly  and  to  free  the  pregnant  tube,  a  procedure  manifestly  impossible 
in  the  true  broad-ligament  variety. 

The  statements  made  by  various  observers  as  to  the  form  of  extra-uterine 
pregnancy  in  any  given  case  are  so  often  based  upon  an  insufficient  examination 
of  the  structures  involved  that  it  is  important  to  keep  clearly  in  mind  the  vari- 
ous criteria  by  wliich  the  exact  form  of  the  extra-uterine  pregnancy  is  estab- 
lished ;  it  is  also  important  that  these  criteria  should  be  adhered  to  in  the 
description  of  a  case.  It  is  a  matter  of  curious  interest  to  note  that  the 
first  bitter  discussion  in  this  well -fought  field  was  one  of  classification,  and  arose 
between  no  less  distinguished  men  than  Mauriceau  and  Regner  de  Graaf,  over  a 
case  occurring  in  1669.  De  Graff  insisted  that  the  woman  from  whom  the  speci- 
men was  received  post  mortem  had  died  of  a  ruptured  tubal  j)regnancy,  while 
Mauriceau  contended  that  the  pregnancy  was  not  tubal  at  all,  but  a  hernia  of 
the  uterine  tissue,  and  he  cited  the  attachment  of  the  round 
ligament  to  the  outer  side  of  the  sac  instead  of  to  the  inner  side 
in  proof  of  his  position,  giving  at  the  same  time  a  clear  sketch  of  the  case. 

Criteria  of  a  Tubal  Pregnancy . — W hen  unruptured,  the 
tumor  is  in  the  tube  and  has  a  pedicle  formed  by  a  part  of  the  tube  and  the 
mesosalpinx,  holding  the  same  relations  to  the  utenis,  broad  ligament,  and  ovary 
as  a  hydrosalpinx  does ;  that  is  to  say,  the  body  of  the  uterus  is  well  defined  and 
separate  from  the  tumor  on  its  inner  (median)  side,  the  ovary  is  found  intact,  and 
the  layers  of  the  broad  ligament  are  not  separated ;  the  round  ligament  lies  on 
the  median  side  of  the  tumor. 

When  the  tubal  jiregnancy  is  ruptured,  if  the  rupture  is  re- 
cent the  fact  is  evident  from  the  extravasated  blood,  and  an  examination  of  the 
tube  shows  the  point  of  laceration ;  or  if  the  case  is  one  of  tubal  abortion  the 
fimbriated  end  is  dilated  and  often  choked  with  firm  clots,  fonning  a  "  tube 
cast."  The  tube  usually  still  contains  a  portion  of  the  ovum,  and  villi  may  even 
be  found  choking  the  tear. 

The  uterus  and  round  ligaments  lie  toward  the  median  line,  the  ovary  is  in- 
tact, and  the  broad  ligament  is  not  spread  apart. 

Criteria  of  an  Intraligamentary  Tubal  Pregnancy. — 
Careful  observation  is  necessary  to  establish  the  diagnosis  of  the  intraliga- 
mentary form  of  extra-uterine  pregnancy,  for  there  is  great  danger  of  confus- 
ing it  with  a  ruptured  intraperitoneal  form  encapsulated  in  adhesions.  The 
following  are  the  criteria  of  differentiation  :  The  tumor  occu]ues  the  same  rela- 
tions to  the  broad  ligament  and  the  uterus  as  does  an  intraligamentary  cyst ;  the 
mesosalpinx  is  unfolded,  together  with  the  anterior  and  posterior  layers  of  the 
broad  ligament,  and  the  pelvic  peritoneum  and  even  the  peritoneum  of  the  ante- 


436  EXTRA-UTERINE    PREGNANCY. 

rior  abdominal  wall  has  become  detaelied  from  the  cellular  tissue  and  covers  the 
tumor  according  as  the  pregnancy  is  more  or  less  advanced. 

The  ovary  lies  somewhere  upon  the  surface  of  the  tumor,  flattened  or  drawn 
out  as  much  as  6  centimeters,  but  the  ovarian  tissue  is  not  distributed  over  any 
■considerable  area,  thus  affording  a  differentiation  from  ovarian  pregnancy.  The 
uterus  lies  closely  applied  to  the  tumor,  deprived  of  its  broad  ligament  on  the 
side  of  the  pregnancy,  and  is  pushed  over  toward  the  opposite  side.  The  round 
ligament  extends  from  the  c  o  r  n  u  uteri  over  the  front  of  the  tumor,  which 
lies  also  in  intimate  relation  with  the  upper  half  of  the  vagina.  Muscular  tissue 
is  often  found  abundantly  in  the  sac  wall  derived  from  the  tube  and  from  the 
subserous  tissue. 

Cases  of  p  s  e  u  d  o  -  i  n  t  r  a  1  i  g  a  m  e  n  t  a  r  y  tumors  are  liable  to  be  mis- 
taken for  this  form,  because  the  pregnant  ruptured  tube  and  the  ovary  are  often 
found  under  a  mass  of  old  adhesions,  which  present  a  smooth  surface  toward 
the  abdominal  cavity,  looking  exactly  like  the  posterior  layer  of  the  broad  liga- 
ment. A  minute  examination  of  the  structures  always  shows  some  irregularities 
in  these  adhesions,  and  by  testing  them,  weak  points  are  found  where  they  can 
be  detached  and  stripped  up  from  the  pelvic  floor  and  walls.  Furthermore,  the 
ovary,  which  ought  to  lie  in  view  in  an  intraligamentary  form,  is  concealed  be- 
neath the  adhesions  in  the  pseudo-intraligamentary  form.  Other  evidences  of 
pelvic  inflammatory  disease  also  exist. 

Criteria  of  an  Interstitial  Pregnancy . — This  form  of  ectopic 
pregnancy  is  distinguished  from  the  commoner  forms  by  the  position  of 
the  round  ligament  on  the  outer  side  of  the  sac,  where  the 
uterine  tube  is  also  found.  The  uterus  is  enlarged  and  intimately  connected 
with  the  inner  side  of  the  tumor,  of  which  it  appears  to  foiin  an  organic 
part. 

The  tubo-uterine  mass  may  bulge  into  the  uterine  cavity  and  be  separated 
from  it  by  a  small  opening  or  may  be  freely  connected  with  it.  When  the 
fetus  escapes  into  the  uterus  the  placenta  stays  behind  in  the  wall  and  commu- 
nicates with  the  uterine  cavity  through  the  opening. 

An  interstitial  pregnancy  is  liable  to  be  confused  vntli  a  pregnancy  in  a 
rudimentary  horn  of  the  uterus,  in  which  the  round  ligament  is  also  found  on 
the  outer  side  of  the  sac.  This  error  will  not  occur  if  the  uterine  body  is  noted 
rounded  off  toward  the  rudimentary  side  and  the  attachment  of  the  pedicle  of 
the  tumor  low  down  on  the  side  of  the  uterus  is  observed. 

The  uterine  tube  is  also  inserted  lower  down  on  the  side  of  the  tumor  than 
it  is  on  the  other  side.  An  interstitial  pregnancy  may  also  become  intraliga- 
mentary (Martin,  Leopold). 

Criteria  of  an  Ovarian  Pregnancy . — In  this  form  it  is  necessary 
to  demonstrate  the  criteria  laid  down  by  Spiegelberg,  namely,  that  the  tube  is 
intact  and  has  no  organic  connection  with  the  gestation  sac  ;  that  the  tumor  is 
connected  with  the  uterus  by  the  utero-ovarian  ligament ;  that  tlie  walls  of  the 
sac  contain  Graafian  follicles  in  various  places ;  and  that  the  albuginea  of  the 
ovary  passes  directly  into  the  tumor  wall. 


CLIXICAL   HISTORY.  437 

Clinical  History. — The  fertilized  ovum  once  lodged  in  the  tube  goes  on  devel- 
oping so  long  as  the  fetus  lives,  which  may  be  up  to  the  eighth  or  ninth  month  of 
pregnancy.  The  first  symptoms  are  identical  with  those  of  uterine  pregnancy. 
There  is  cessation  of  the  menses,  morning  sickness,  uncomfortable  sensations 
and  fullness  in  the  breasts,  enlargement  of  the  uterus,  and  discoloration  of  the 
vagina.  The  patient  is  often  impressed  with  the  fact  that  she  is  pregnant.  A 
tumor  forms  to  the  right  or  left  of  the  uterus,  elastic  and  painful  to  touch, 
which  grows  from  month  to  month,  while  the  uterus  itself  enlarges  to  the  size 
of  a  two  or  three  months'  pregnancy. 

Sometimes  within  the  lirst  five  or  six  months  the  uterus  may  cast  off  the 
decidua  vera  which  has  formed  in  it,  either  as  a  complete  cast  of  the  in- 
terior of  the  uterine  cavity  or  in  pieces.  This  process  is  accompanied  by  a  flow 
of  blood  from  the  vagina  which  is  aj)t  to  be  mistaken  for  an  abortion,  and  may 
be  so  excessive  as  almost  to  endanger  life. 

The  tumor  continues  growing  and  liecomes  apparent  on  one  or  the  other 
side  of  the  lower  al)domen,  where  it  may  be  discovei-ed  for  the  first  time  by  the 
patient  herself.  About  the  fourth  or  fifth  month,  and  sometimes  earlier,  colos- 
trum appears  in  the  breasts. 

Attacks  of  pain  and  localized  peritonitis  due  to  rupture  of  the  sac  walls 
and  to  hemorrhage  from  the  detachment  of  some  of  the  villi  or  of  the  placenta 
are  frequently  observed.  These  attacks  are  apt  to  he  sudden  and  severe,  and 
the  pain  is  often  described  as  "  agonizing."  When  the  hemorrhage  is  sudden 
and  excessive  the  patient  falls  in  collapse  ;  hut,  in  spite  of  these  alarming  symp- 
toms, she  may  survive  a  succession  of  similar  attacks  and  the  fetus  and  sac  may 
continue  to  develop.  The  pelvic  peritonitis  produces  adhesions  between  the  sac 
and  the  surrounding  parts,  and  is  often  accompanied  hy  a  modei'ate  elevation  of 
temperature. 

About  the  fifth  month  the  fetal  m  o  v  e  m  e  n  t  s  may  be  felt,  and  later  the 
fetal  heart  sounds  and  the  placental  soutfie  may  be  heard. 

The  discharges  of  blood  from  the  uterus  after  the  escape  of  the  decidua  be- 
come irregular  and  are  often  })rotracted. 

If  the  fetus  survive  the  risks  of  rupture,  hemorrhage,  and  the  partial  detach- 
ment of  the  sac  in  the  early  months,  false  labor,  simulating  the  onset  of  a  mis- 
carriage or  a  tnie  labor,  may  occur  at  any  time  during  the  latter  months  of 
pregnancy,  followed  by  the  death  of  the  child  and  cessation  of  its  movements, 
the  absorption  of  the  amniotic  fluid,  and  the  rapid  diminution  in  the  size  of  the 
sac.  These  cases  are  undoubtedly  the  "missed  labors"  of  our  predecessors 
(Oldham). 

In  rare  instances  the  pregnancy  advances  to  full  term 
without  any  untoward  event  just  as  a  uterine  pregnancy  ;  then  at  or  near  term 
false  labor  sets  in,  the  fetus  dies,  and  remains  behind  with  the  placenta  as  a 
foreign  hody,  which  may  lie  undisturbed  within  the  tulie  for  many  years,  be- 
coming calcified  (lithopedion)  and  converted  into  adipocere,  (»r  it  may  be  skele- 
tonized by  the  removal  of  large  portions  by  the  phagocytes.  In  a  case  cited 
by  Brendel  {Centralb.  f.  Gyn.,  1SS3,  p.  i'A\))  a  dead  fetus  in  the  eighth  month 


438 


EXTRA-UTERINE    PREGNANCY. 


was  the  meclianical  cause  of  an  obstinate  constipation  which  lasted  four  wrecks. 
Cases  of  ileus  have  also  occurred  due  to  strangulation  of  the  intestines  by  peri- 
toneal bands.  At  any  date  subsequent  to  the  fetal  death  inflammatory  changes 
may  be  set  up,  and  the  abdominal  w^all  or  some  of  tlie  hollow  viscera  may  be 
perforated  in  the  discharge  of  the  fetal  bones. 

The  fetus  itself  may  be  perfectly  formed  and  well  developed,  but  in  a 
large  percentage  of  cases  it  is  either  puny  or  deformed  from  insufficient  nourish- 
ment and  undue  pressure  ou  certain  parts  in  a  constrained  position.  Kirch- 
hoff  {Central}),  f.  Gyn.,  1894,  p.  232)  found  a  double  fetal  monster  (tlioraco- 
p a g u s)  in  a  left  tube  ruptured  in  the  tif th  week.  A  large  hydramnios 
resembling  an  ovarian  cyst  has  been  noted  (Teuffel,  Arch.f.  Gyn.,  Bd.  xxii,  p.  57). 
Torsion  and  atrophy  of  the  umbilical  cord  may  also  occur  (see  Fig.  521). 
The  he m  o r  r h a g e  in  extra-uterine  pregnancy  is  one  of  its  most  charac- 
teristic features,  and  is  due,  as  stated,  either  to  the  detachment  of  some  part  of 

the  ovum  from  the  tubal  wall  or  to  a  tear  in  the  wall 
of  the  tube  unable  any  longer  to  accommodate  the 
growing  ovum.  Hemorrhage  may  take  place  into  the 
extra- uterine  sac  itself,  into  its  walls,  into  the  lumen 
of  the  tube,  into  the  abdominal  cavity,  or  between  the 
layers  of  the  peritoneum.  Hemorrhage  into  the  tube 
and  by  its  fimbriated  end  out  into  the  abdominal  cav- 
ity, and  hemorrhage  due  to  rupture  of  the  tube  into 
the  abdominal  cavity,  are  the  most  important  clinical 
varieties. 

Owing  to  the  tenuity  of  the  tubal  walls  as  they 
become  distended  by  the  growing  fetus,  rupture 
frequently  occurs  early  in  the  pregnancy  any- 
where from  the  fourth  week  to  the  fourth  or  fifth 
month  or  later.  The  reason  for  the  thinning  out  of 
the  wall  in  one  direction  more  than  in  another  has 
l)een  the  subject  of  much  speculation.  Christian  Fen- 
ger  suggests  that  when  the  ovum  is  lodged  near  the 
center  of  the  tube  surrounded  on  all  sides  by  its  folds 
it  is  less  likely  to  rupture  than  if  it  lodges  down  be- 
tween two  folds  close  to  the  tubal  wall.  Landau  found 
in  his  case  of  extra-uterine  j^regnancy  lodged  in  a  diverticulum  of  the  tube, 
that  the  ovum  lay  immediately  beneath  the  peritoneum,  and  the  rest  of  the 
muscular  wall  of  the  tube  was  almost  unchanged. 

In  a  case  of  my  own  of  right  isthmial  pregnancy  the  patient  had  not  even 
missed  a  menstrual  period  when  she  was  suddenly  taken  vnih.  violent  pains,  in- 
terpreted as  colic  from  indigestion,  and  bled  to  death  in  two  days  from  a  little 
mass  not  larger  than  a  bean,  about  1x2  centimeters  in  size,  ruptured  on  the 
dorsal  surface. 

After  the  rupture  of  the  tube  the  fetus  may  escape  into  the  ab- 
dominal cavity  and    continue  to  develop.     The  usual  course,  how- 


FiG.  521. — Fetus  and  Umbil- 
ical   CoKI)    FOUND    LVINti 

AMONG  Clots  in  Abdomi- 
nal Cavity.  January 
27, 1896.     JS'atuual  Sizk. 


CLINICAL   HISTORY. 


439 


Fig.  522. — Extka-uterine  rREGNANCY. 
Showing  the  rupture  in  the  ampulla  and  the  escape 
of  the  fetus,  which  is  still  attached  by  its  cord ;  the 
ovary  is  intact  below  the  sack.     Operation  by  Dr.  Feck, 
of  Youngstown,  O.     Recovery.     J^  natural  size. 


ever,  is  the  death  of  the  fetus  and  the  formation  of  an  extensive  mass  of  blood 
clots  which  may  be  walled  off  from  the  abdominal  cavity  by  intestinal  adhesions. 
It  often  happens  that  the  first  liemorrhage,  even  when  occurring  as  early  as 
the  second  month,  proves  fatal.  This  was  the  condition  in  the  case  of  an  Eng- 
lish actress  who  dropped  dead  in  a 
cafe  in  Paris  in  whom  a  ruptured 
extra-uterine  pregnancy  was  found 
when  the  viscera  were  examined  un- 
der the  impression  that  she  had  died 
of  poisoning  (Chahbazian,  Trans,  of 
the  Ohs.  Sac.  (f  London,  vol.  xxiv,  p. 
157).  On  the  other  hand,  the  pa- 
tient may  die  of  anemia  after  a  suc- 
cession of  hemorrhages. 

The  amount  of  the  hemorrhage 
depends  ujjon  the  position  of  the 
rupture,  whether  it  happens  to  in- 
volve a  large  blood  vessel  or  not, 
and  the  hemorrhage  is  particularly 
dangerous  when  it  lies  within  the  placental  site.  Eej^eated  hemorrhages  occur 
when  there  is  a  partial  rupture  and  the  ovum  continues  to  grow.  The  hemor- 
rliage  may  often  be  checked  temjjorarily  by  a  clot  or  by  some  tufts  of  placental 
villi ;  it  is  not  so  likely  to  prove  fatal  when  it  takes  place  between  the  layers 
of  the  mesosalpinx,  and  so  opens  up  the  broad  ligament,  becoming  extraperi- 
toneal and  lying  under  the  pehdc  peritoneum. 

Not  infrequently  the  pregnancy  terminates  with  the  escape  and  death  of  the 
ovum,  with  the  extravasation  of  blood  into  the  peritoneum,  and  the  entire  ab- 

sorjition  of  the  abnormal 
products,  and  the  case  is  in- 
terpreted by  the  family  phy- 
sician as  simply  one  of 
severe  colic. 

T  u  b  a  1  A  b  o  r  t  i  o  n . — 
AVlien  the  ovum  lies  in  the 
am])ullar  end  of  the  tube  and 
becomes  detached  early  in 
the  pregnancy,  the  succes- 
sive hcmorrhnges  often  ac- 
cumulate around  it  and  take 
the  shape  of  the  distensible 
tube  (extra  -  uterine  tul)e 
Fio.  523.  —  KiPTiuEi)  Lekt  Extka- itkkine  Pkk.inancy  with     cast).      The  cast  formed  in 

LaKOE,   FkEK    iNTKAI-KKnuNEAL    IIeMuUU.LVOE.  ^J^|g  ^^^^     SOmCWhat    tlie 

ihe  rupture  is  at  the  junction  ot  the  aiupulla  and  the  istliiniis  ;  •' 

the  rest  of  the  aiiif>ulla  is  dilated  and  infiltrated  down  to  a  narrow  appearance    of   a  SaUSagG,   IS 

neck  just  behind  the  tinihriated  end.     Enucleation :  saline  infusion.  i-     i    •      i    <•  r>  j.      o 

Kecovery.     Feb.  25,  1S'J5.     iXatural  size.  CylmdriCal,  trom  2  tO  6  Cen- 


4-10 


EXTRA-UTEKINE    PREGNANCY. 


timeters  in  diameter  and  5  or  6  centimeters  in  length,  and  at  the  outer  end 
which  projects  from  the  ampulla  it  is  ragged  and  broken.  These  blood  casts  are 
often  found  in  situ,  choking  the  tube,  or  lying  free  in  the  peritoneal  cavity 
amid  a  mass  of  clots ;  in  the  latter  case  they  are  apt  to  be  broken  up  in  the 
removal  and  so  not  recognized. 

In  rare  instances  very  little  hemorrhage  accompanies  the  tubal  abortion,  and 
the  fetus  and  its  membranes  may  be  extruded  hi  toto  through  the  fimbriated  ex- 
tremity. In  a  specimen  ex- 
hibited by  Dr.  Edebohls  before 
the  N^ew  York  Obstetrical  So- 
ciety the  fetus  with  its  mem- 
branes intact  was  seen  in  the 
process  of  abortion,  one  half 
of  the  ovum  being  free  in  the 
peritoneal  cavity,  while  the 
other  half  was  firmly  grasped 
by  the  dilated  conical  fimbri- 
ated end  of  the  tube,  like  a 
bud  in  its  calyx. 

The  fetus,  turned  into  the 
peritoneal  cavity  with  a  mass 
of  clots,  by  rupture  of  the  sac 
dies,  and  the  sac  becomes 
walled  off  by  adhesions  from 
the  rest  of  the  cavity.  Later 
suppuration  may  occur,  with 
perforation  and  discharge  of 
the  contents  by  the  rectum, 
vaginal  vault,  bladder,  or  ab- 
dominal walls. 

Tubal  Mole  .—A  not 
infrequent  termination  of  tu- 
bal pregnancy  is  the  death 
of  the  fetus  in  the  intact 
tube,  with  marked  hemorrhage 
about  it  and  between  its  mem- 
branes. At  the  same  time  the 
liquor  amnii  is  absorbed,  the  blood  more  or  less  organized,  and  a  structure 
produced  which  is  identical  with  the  moles  occurring  in  uterine  pregnancy. 
Such  moles  may  vary  markedly  in  size,  according  to  the  age  of  the  pregnancy 
and  the  amount  of  hemorrhages,  and  may  be  retained  in  the  tube  for  an  indefi- 
nite period. 

I  have  seen  two  cases  of  unruptured  extra-uterine  pregnancy  terminate  in 
this  way;  in  the  first  the  pregnancy  was  four  months  advanced  in  the  ampullar 
end  of  the  right  tube,  and  in  the  second  there  was  a  tumor  of  the  isthmial  end  of 


Fio.  524. — Extra-uterine  Pregnancy. 
Showing  the  thickened  tube  and  adhesions  to  tlic  tube  and 
ovary.  The  black  nia.ss  above  the  tube  is  a  blood  clot  fonuinu; 
a  perfect  tube  cast  which  had  been  thrown  oft"  into  the  abdoini- 
ual  cavity.  Operation.  Kecovery.  Path.  No.  417.  %  natui-al 
size. 


MULTIPLE    PREGNANCY. 


441 


the  right  tube  about  the  size  of  a  walnut.  On  cutting  through  this  it  was  found 
to  consist  of  a  firm  old  blood  clot  embraced  on  all  sides  by  the  thin  tubal  wall. 

Interstitial  Pregnancy  . — When  the  pregnancy  takes  place  in  that 
part  of  the  tube  which  lies  ^vithin  the  uterine  wall,  the  growing  ovum  may 
gradually  become  extruded  into  the  uterine  cavity,  while  the  placenta  retains  its 
connection  with  the  sac  within  the  cornu,  where  it  may  be  found  and  removed 
after  the  deUvery  of  the  child  by  the  natural  way. 

Interstitial  pregnancy  is  peculiarly  liable  to  rupture  into  the  abdominal  cavity 
with  an  immediately  fatal  hemorrhage,  or  it  may  again  rupture  between  the 
layers  of  the  broad  ligament. 

To  recapitulate,  unless  artificially  relieved,  an  extra- 
uterine pregnancy  always  terminates  fatally  to  the  child, 
and   is  frequently  fatal  to  the  mother. 

The  following  is  a  categorical  statement  of  the  final  re- 
sults: 

1.  Development  of  the  fetus  within  the  tube,  with  false  labor  and  death  of 
the    fetus,  which  is  retained  as 
a  lithopedion,  or  is  mummified, 
or    discharged     with     suppura- 
tion. 

2.  Tubal  mole. 

3.  Tubal  abortion. 

4.  Extrusion  into  the  uterus 
(in  the  interstitial  form),  and 
development  to  term. 

5.  Rupture  within  the  folds 
of  the  broad  ligament,  usually 
with  the  death  of  the  fetus,  in 
rare  instances  advancing  to 
term. 

6.  Rupture  into  the  perito- 
neal cavity. 

(a)  Followed  by  continued 
growth  of  the  fetus. 

(b)  Death  of  fetus  and 
mother. 

(c)  Death  of  fetus  alone  with  absorption  (Leopold,  Archlvf.  Gyn.,  xviii,  p. 
53  ;  experiments  on  rabbits). 

(d)  Death  of  fetus  with  a  succession  of  hemorrhages  ending  in  (1)  suppura- 
tion, peritonitis,  and  maternal  death ;  (2)  suppuration  and  discharge  externally 
by  the  rectum,  by  the  vagina,  by  the  l)ladder,  or  by  the  abdominal  walls. 

Multiple  Pregnancy. — Numerous  observations  are  recorded  in  which  an  extra- 
uterine and  an  iiitra-uterine  pregnancy  have  occurred  simultaneously. 

The  course  under  such  circumstances  may  be  that  of  an  extra-uterine  preg- 
nancy with  death  of  the  fetus,  followed  later,  it  may  be  several  years  later,  by 


Fio.  525.- 


Extra-uterine  Tibal   Mole   filling   and   dis- 
tending THE  Ampulla. 
The  isthmus  is  not  attectcd,  and  the  fimbriated  end  is  not 
at  all  distended.    There  was  no  free  blood  in  tlie  pelvis.    One 
half  of  the  ovary  left.     Operation.     Eecovery.    Oct.  20, 1897. 
Natural  size. 


442  EXTRA-UTERINE    PREGNANCY. 

an  intra-uterine  pregnancy  (see  Coe,  Avier.  Jour.  Ohs.,  1893,  vol.  xxvii,  p.  855). 
The  uterine  pregnancy  may  then  go  on  to  term,  or  may  terminate  prematurely 
in  abortion.  Inasmuch  as  the  intra-uterine  pregnancy  is  not  abnormal,  the  in- 
dications for  treatment  must  depend  upon  the  extra-uterine  pregnancy.  Out  of 
eighteen  cases  (see  Gutzwiller,  ArcJiiv  f.  Gyn.,  Bd.  xliii,  p.  223),  ten  maternal 
lives  were  lost,  and  of  the  remaining  eight,  four  were  saved  by  celiotomies.  In 
one  case  both  children  were  delivered  alive,  but  the  mother  died.  In  the  case 
contributed  by  Gutzwiller  the  extra-uterine  pregnancy  advanced  to  the  eighth 
month  and  the  fetus  died  after  an  injury,  and  the  intrauterine  pregnancy 
began  shortly  afterward ;  twelve  months  after  the  beginning  of  the  extra-uter- 
ine pregnancy  it  was  discovered  and  operated  upon,  and  the  second  day  after  its 
removal  a  three-months'  fetus  wa§  discharged  from  the  uterus. 

Spencer  AYells  made  a  diagnosis  of  simultaneous  extra-uterine  and  intra- 
uterine pregnancy  in  a  case  in  which  there  was  an  enlarged  pregnant  uterus  with 
a  tumor  attached  to  it,  by  hearing  both  fetal  heart  sounds. 

In  a  patient  who  came  under  the  care  of  A.  L.  Galabin  {Trans,  of  the  Ohs. 
Soc.  of  London,  vol.  xxiii,  1881,  p.  140)  there  were  two  fluctuating  tumors  sepa- 
rated by  a  distinct  sulcus,  one  on  the  right  side  reaching  to  the  ribs,  and  one  on 
the  left  side  occupying  the  left  inguinal  and  iliac  regions.  Fetal  movements  and 
heart  sounds  and  a  uterine  souffle  were  heard  in  the  left  enlargement  only ;  in 
the  right  tumor  a  hard  body  could  be  palpated  through  the  fluid ;  a  significant 
point  in  the  history  was  the  fact  that  the  patient  began  to  complain  suddenly  of 
great  pain  and  faintness,  and  developed  a  marked  peritonitis.  The  diagnosis  lay 
between  a  ruptured  ovarian  cyst  and  an  extra-uterine  fetation  combined  with 
an  intra-uterine  one,  and  the  latter  was  found  at  the  operation. 

The  late  Dr.  H.  P.  C.  Wilson,  of  Baltimore,  had  the  good  fortune  to  save 
both  the  extra-uterine  and  the  intra-uterine  child  in  the  case  of  a  woman, 
twenty -four  years  old,  in  her  fourth  j>regnancy.  She  bore  a  female  child  in  easy 
labor  April  15,  1880,  a  month  before  the  calculated  time ;  it  was  at  once  evident 
to  both  patient  and  midwife  that  there  was  another  child  present.  An  examina- 
tion showed  that  the  tumor  in  the  abdomen  was  perfectly  independent  of  the 
uterus,  and  on  auscultating  it,  fetal  heart  sounds  were  detected.  The  effort  was 
then  made  to  delay  operation  at  least  twenty -three  days  until  the  full  term  for 
the  intra-uterine  gestation  had  arrived.  The  patient  had  several  attacks  of  colic 
and  laborlike  pains,  which  were  quieted  by  opiates.  The  oi^eration  was  done 
May  11,  1880;  the  abdomen  was  opened,  and  a  sac  exposed  which  ruptured 
under  slight  manipulation,  discharging  about  2  liters  of  amniotic  fluid,  and  a 
male  infant  weighing  eight  pounds  was  delivered.  The  child  lay  well  flexed  in 
the  abdomen  with  buttocks  down  and  back  turned  forward.  The  sac  was  sewed 
to  the  abdominal  incision  and  drained.  The  patient  died  of  sepsis  ninety  hours 
after  the  operation. 

Chr.  Fenger  has  found  two  ova  in  the  same  tube,  and  Sanger  even  found  a 
case  of  triplets,  two  of  which  constituted  an  intramural  twin  ovum,  while  the 
third  was  lodged  in  the  ampulla.  A  number  of  cases  have  been  reported  of 
extra-uterine  pregnancy  occurring  in  both  tubes  simultaneously. 


REPEATED    EXTRA-UTERIXE    PREGXANCIES.  443 

Repeated  Extra-uterine  Pregnancies. — -Cases  are  recorded  in  which  an  extra- 
uterine pregnancy  has  been  observed  twice  in  the  same  woman.  Taylor,  of 
Birmingham,  had  a  patient  who  missed  one  menstruation,  and  when  six  weeks 
pregnant  had  a  rupture,  with  the  formation  of  a  hematocele  and  peritonitis. 
Two  years  after,  she  had  a  ruptured  extra-uterine  pregnancy  at  tive  weeks,  and 
when  the  abdomen  was  opened  and  the  mass  removed  the  scar  of  the 
previous  rupture  was  found  in  the  tube. 

Olshausen,  at  the  meeting  of  the  Berlin  Obstetrical  and  Gynecological  So- 
ciety, Dec.  13,  1889,  exhibited  a  child  in  good  condition  and  over  a  year  old, 
delivered  from  a  right  tubal  pregnancy.  The  month  before  the  meeting  he  liad 
operated  successfully  a  second  time  upon  the  mother  for  a  left  tubal  pregnancy 
in  the  fifth  week  (see  Gent.f.  Gijn.^  1890,  p.  67). 

Hermann  {Brit.  Med.  Jour.,  Sept.  27,  1890)  removed  a  ruptured  tubal  preg- 
nancy, and  three  years  later  diagnosed  an  unruptured  pregnancy  on  the  opposite 
side.  Reference  has  already  been  made  to  Coe's  case,  in  which  there  was  an 
interval  of  twelve  years  between  the  two  j)regnancie8  {Trans.  Amer.  Gyn.  Soc, 
1893,  xviii,  p.  268). 

F.  Schauta  {Lehrh.  d.  gesammt  Gynakologie,  1895,  p.  681)  would  explain  this 
accident  by  the  occurrence  of  a  one-sided  tubal  catarrh  offering  an  obstruction 
and  causing  a  pregnancy  on  that  side,  followed  at  a  later  date  by  a  catarrh  of 
the  opjiosite  side  with  a  pregnancy  on  that  side. 

Diagnosis. — The  diagnosis  of  an  extra-uterine  pregnancy  is  usually  easy  to 
make.  The  diagnostic  signs  vary,  however,  according  to  the  advancement  of 
the  pregnancy  and  according  as  the  sac  is  ruptured  or  unruptured,  and  the  fetus 
ahve  or  dead. 

The  two  important  means  of  making  the  diagnosis  are  the  history  of  the  case 
and  the  physical  examination,  either  of  which  may  be  sufficient  alone,  but  both 
together  often  afford  a  degree  of  certainty  fully  as  great  as  that  attained  in  the 
case  of  any  other  abdominal  tumor. 

The    diagnostic    signs   are  the  following : 

1.  Cessation  of  menstruation. 

2.  Other  signs  of  pregnancy,  such  as  nausea,  changes  in  the  breasts,  etc.,  and 
certain  characteristic  signs,  often  peculiar  to  the  individual. 

3.  The  patient  often  "  feels  different "  in  this  pregnancy  as  compared  to  jire- 
vious  ones,  and  suspects  that  something  is  wrong. 

4.  Pains  in  tlie  pelvis  and  the  presence  of  a  tumor,  which  is  distinct  from  the 
uterus  and  sensitive  upon  pressure. 

5.  Sudden  severe  (agonizing)  pain,  often  coming  on  during  active  exertion. 

6.  Patient  is  compelled  to  go  to  bed  with  marked  anemia  or  in  collapse. 

7.  Repeated  attacks  of  pain  and  signs  of  pelvic  peritonitis. 

8.  Constipation  and  dysuria. 

9.  Recurrences  of  irregular,  more  or  less  profuse,  menstruation. 

10.  Discharge  of  decidual  cast. 

11.  After  rupture  the  patient  may  have  hallucinations,  often  becomes  weak 
and  emaciated,  and  in  some  cases  there  is  marked  nephritis. 


444  EXTRA-UTERINE    PREGNANCY. 

Objective  Signs. — 1.  Uterus  enlarged  to  about  tlie  size  of  a  two- 
months'  pregnancy. 

2.  Formation  of  a  tumor  at  one  or  the  other  side  of  the  uterus. 

3.  Microsco^jic  demonstration  of  the  decidual  nature  of  cast  -  off  mem- 
brane. 

4.  Contraction  of  the  uterus  after  casting  off  the  decidua. 

5.  Occasionally  contraction  may  be  felt  in  the  extra-uterine  tumor. 

6.  If  the  pregnancy  continues  to  develop,  the  abdomen  increases  in  size  and 
the  fetus  can  be  felt  with  great  distinctness  through  the  thin  sac  wall,  and  fetal 
heart  sounds  are  heard. 

7.  False  labor  which  sets  in  from  the  seventh  to  the  tenth  month,  fol- 
lowed by  death  of  fetus  and  absorption  of  amniotic  fluid,  with  rapid  diminution 
in  the  size  of  the  tumor.  The  dead  fetus  and  the  membranes  may  then  remain 
in  the  abdomen  innocuous  for  years,  or  the  sac  may  supjDurate  at  any  period 
after  tlie  death  of  the  fetus,  and  excite  a  fatal  peritonitis,  or  discharge  the 
fetal  bones  through  the  abdominal  walls  or  into  the  intestinal  canal,  bladder,  or 
vagina. 

Dr.  Routh,  of  London,  has  stated  that  a  positive  diagnosis  may  be 
made  if  a  deciduals  cast  off  from  the  uteriisin  the  pres- 
ence   of   a   growing   pelvic   tumor. 

The  history  of  the  case  often  shows  tliat  the  woman  has  been  sterile 
for  some  time — it  may  be  as  long  as  ten  or  twelve  years — and  a  close  investigation 
generally  reveals  the  fact  that  there  has  been  some  catarrhal  process  in  the 
uterus  and  in  the  tubes  with  attacks  of  pelvic  peritonitis. 

Menstruation,  which  has  been  regular,  has  suddenly 
ceased  for  one  or  more  months,  when  it  returns  in  an  ir- 
regular way  at  intervals  of  two  or  three  weeks,  often 
lasting   from   ten   to   fifteen    days   or   more. 

It  may  be  difficult  to  reckon  how  far  the  extra-uterine  pregnancy  has  pro- 
gressed for  several  reasons.  Patients  suffering  from  pelvic  inflammatory  disease 
are  often  irregular  in  their  periods  ;  one  of  my  cases  occurred  dur- 
ing lactation,  and  this  has  been  noted  before  ;  menstruation  sometimes  con- 
tinues for  a  month  or  two  in  spite  of  the  extra-uterine  pregnancy,  and  the 
irregular  menstrual  flow  common  during  the  first  half  of  the  pregnancy  is  con- 
fusing. 

In  addition  to  the  difficulty  of  fixing  a  precise  date  of  onset,  there  is  the 
added  difficulty  that  the  size  of  the  sac  does  not  often  corre- 
spond to  the  month  of  the  pregnancy;  it  may  grow  rapidly  (hy- 
dramnios),  or  it  may  remain  small.  Wlien  hemorrhages  occur  in  a  pregnancy 
in  the  fifth  or  sixth  week,  it  may  even  appear  to  be  a  four  or  five  month's 
ovum,  judged  by  its  size  alone.  This  difficulty,  however,  does  not  affect  the 
practical  result,  for  in  the  first  five  months  the  same  treatment  is  employed, 
whether  the  pregnancy  is  reckoned  one  or  two  months  earlier  or  later,  and  at 
the  latter  date  the  fetus  can  usually  be  measured  and  data  taken  from  its  size  to 
determine  its  viability. 


REPEATED    EXTRA-UTERHSTE    PREGXANCIES.  4-15 

Although  the  diagnosis  can  be  readily  made  in  the  majority  of  cases,  occa- 
sional instances  will  occur  when  the  true  nature  of  the  malady  vnll  be  suspected 
for  the  first  time  when  the  abdomen  has  been  opened  and  the  tube  incised  and 
found  to  contain  laminated  clots  (see  Fig.  526). 

In  all  doubtful  cases  the  microscopic  examination,  showing  the  presence  of 
placental  tissue,  chronic  villi,  and  decidual  cells,  affords  the  one  positive  criterion 
by  which  the  nature  of  the  case  is  determined  beyond  a  doubt  (see  Plate 
XXIII). 

The  Diagnosis  in  Unruptured  Cases . — When  the  sac  is  un- 
ruptured the  diagnostic  factors  are  not  so  numerous  as  in  ruptured  cases. 
They  are  : 

Cessation  of  menstruation  for  one  or  more  periods,  accompanied  by  nausea 
and  the  other  signs  which  lead  the  patient  herself  to  suspect  pregnancy. 

Changes  in  the  color  of  the  genital  mucous  membranes. 

The  existence  of  an  ovoid  tumor  to  the  right  or  left  of  the  uterus  in  the 
position  of  the  uterine  tube,  usually  painful  on  pressure. 

The  sac  must  be  handled  gently  for  fear  of  rupturing  it  during  the  examina- 
tion. Some  of  the  earlier  writers  thought  that  a  differential  diagnosis  between 
extra-uterine  and  intra-uterine  pregnancy  could  be  made  by  the  failure  of  the 
extra-uterine  sac  to  contract,  l)ut  this  sign  is  fallacious,  as  distinct  contractions 
have  been  noted. 

The  uterus  may  lie  in  anteposition  or  in  retroflexion, 
and  when  the  extra-uterine  sac  becomes  larger  than  an 
egg  the  womb  is  thrust  over  toward  the  opposite  side. 

If  the  uterine  decidua  is  cast  off,  or  bits  may  be  re- 
moved by  curettage,  this  constitutes  a  sign  of  the  utmost     ^ 

*'  °    '  °  Fig.  52(3. — h.\TU.\-rTERiNE 

value.  Pregnancy  ;  Ckoss  Sec- 

AVhen  the  fetus  dies  without  rupture  of  the  tube,  the  Wall  in  the  ampulla. 
absorption  of  the  amniotic  fluid,  causing  a  rapid  diminu-         Showin-r  the  placenta 

^  ..,,,.,  •■  on  tlie  left  and  blood  clots 

tion  of  the  size  of  the  sac,  is  a  sign  which  is  almost  pathog-     on  the  right,  chokinfj  the 

tube,  wliich  is  thinned  out 
nomoniC.  in  the  neifrhborhood  of  the 

From  the  third  month  on,  the  presence  of  milk  in  the  '}.Xn-,x\  ^\zo!'  ^'''  ^^^' 
breasts. 

The  first  case,  as  far  as  I  know,  in  which  an  unruptured  extra-uterine  preg- 
nancy was  diagnosed  and  operated  upon  in  America  was  that  of  one  of  my  pa- 
tients in  Kensington,  Philadelphia,  which  may  serve  as  a  type  on  account  of  the 
characteristic  history  presented  {Trans.  Ohst.  and  Oijn.  Society  of  Bait.,  Jan.  1-i 
and  Feb.  11,  1890). 

J.  B.  was  twenty-two  years  old  and  had  been  married  for  three  years.  She 
had  liad  one  premature  still-birth,  and  one  child  eleven  montiis  before  I  saw 
her.  She  came  to  me  early  in  December,  1885,  stating  that  her  nienstrnatiou 
had  been  regular  up  to  July,  but  that  she  had  not  menstruated  from  July  until 
the  middle  of  Noveml)er,  when  she  discharged  something  like  a  })iece  of  flesh. 
In  October  she  had  noticed  a  painful  swelling  low  down  on  the  right  side ;  tlie 
pain  was  severe  and  continuous  until  the  menstrual  flow  came  on  and  relieved  it. 


446  EXTRA-UTERIXE    PREGNANCY. 

Upon  examination,  I  found  a  little  milk  in  the  flaccid  breasts,  and  a  smooth, 
tense,  elastic  ovoid  tumor  filling  the  right  side  of  the  pelvis  anterior  to  the  cer- 
vix,* which  was  displaced  back  into  the  sacral  hollow.  The  tumor  was  felt 
in  close  contact  with  the  whole  anterior  vaginal  wall  ;  it  was  moderately  mov- 
able, and  its  posterior  pole  lay  close  to  the  right  uterine  cornu,  and  felt  as  if 
pivoted  there.  It  filled  the  lower  abdomen  on  the  right  side  halfway  up  to  the 
umbilicus,  and  gave  a  peculiar  tense,  elastic  sensation  on  pressure.  The  uterus 
was  small  and  retroposed,  reclining  in  the  sacral  hollow. 

At  her  next  visit  she  said  she  thought  she  nmst  be  pregnant,  as  she  had  felt 
slight  movements. 

On  Dec.  16th,  a  month  after  the  discharge  of  the  decidua,  she  had  a  slight 
flow  without  any  pain,  and  on  the  12th  of  January  she  had  a  free  discharge, 
fighter  in  color  than  normal  menstruation,  and  again  on  the  8tli  of  March  she 
had  a  free  flow  lasting  until  the  13th.  The  following  note  was  made  on  this 
date :  "  Uterus  small,  low  down  in  the  hollow  of  the  sacrum.  By  palpation 
through  the  anterior  vaginal  wall  an  ovoid,  tense  cyst  is  felt  on  the  right  side, 
about  12  centimeters  in  length  by  7  centimeters  in  breadth.  The  axis  of  the 
cyst  lies  in  the  plane  of  the  superior  strait ;  its  anterior  extremity  lies  at  the 
symphysis  pubis  to  the  right,  while  its  posterior  extremity  is  at  the  right  cornu 
uteri.  A  well-defined  sulcus  lies  between  the  tumor  and  uterus,  which  are  con- 
nected by  a  short  but  easily  recognizable  pedicle.  The  tumor  is  very 
sensitive  to  pressure.  It  is  very  smooth,  and  has  a  remarkable  elastic 
feeling  like  a  rubber  ball ;  there  is  much  tenderness  on  the  left  side,  low  down,' 
where  there  is  an  indistinct  wormlike  feeling  about  the  retroposed  cornu  uteri." 

The  tumor  when  first  seen  had  extended  out  of  the  pel- 
vis halfway  up  to  t li e  umbilicus,  and  had  therefore  mark- 
edly  diminished   in   size   while   under   observation. 

The  diagnosis  of  an  extra-uterine  j)regnancy  was  therefore  positively  made 
upon  the  basis  of  the  following  signs:  Cessation  of  menstruation  for  several 
months,  some  enlargement  of  the  uterus,  the  formation  of  a  cystic  tumor  lateral 
to  the  uterus,  the  appearance  of  milk  in  the  breasts,  the  expulsion  of  a  mem- 
brane resembling  a  cast  from  the  uterus,  unusual  pains  in  the  lower  abdomen, 
a  shrinkage  of  the  sac  while  under  observation— a  group  of  signs  found  in  no 
other  condition  than  extra-uterine  pregnancy. 

The  operation,  performed  March  20,  1886,  in  the  presence  of  Dr.  R.  P. 
Harris  and  several  other  physicians,  revealed  a  right-sided  unruptured  extra- 
uterine sac,  10|  centimeters  long,  developed  in  about  the  middle  of  the  uterine 
tube.  The  sac  was  cut  open  by  Dr.  C.  H.  Thomas,  when  it  extruded  a  shrunken 
but  well-formed  male  fetus,  12  centimeters  long,  from  vertex  to  rump. 

The  patient  recovered  and  became  normally  pregnant  the  following  month, 
and  I  delivered  her  in  January,  1887,  after  a  difficult  forceps  operation. 

Although  the  diagnosis  in  an  unruptured  case  may  sometimes  be  easy,  mis- 
takes may  also  occur,  especially  when  the  patient  is  seen  but  once,  I  made  such 
an  error  soon  after  the  case  cited  above.  A  young  married  woman  came  to  me 
complaining  of  sudden  cessation  of  menstruation  with  severe  pain  in  the  right 


REPEATED    EXTRA-UTERIXE    PREGXANCIES.  447 

side.  On  examination,  I  found  an  elastic  tumor,  5  centimeters  in  diameter,  to 
the  right  of  a  normal  uterus,  and  suspected  an  extra-uterine  pregnancy,  but  on 
•  removal  the  tumor  proved  to  be  a  corpus-luteum  cyst,  and  the  cessation  of 
menstruation  "sras  due  to  phthisis,  which  developed  rapidly  later. 

The  Diagnosis  in  Ruptured  Cases . — The  diagnosis  of  a  rup- 
tured extra-uterine  pregnancy  depends  upon  the  sudden  onset  of  the 
severe  symptoms,  such  as  extreme  pain  localized  in  the  pelvis,  followed 
by  anemia,  and  usually  associated  with  a  discharge  of  blood  from 
the  uterus,  indicating  rupture,  and  often  resulting  in  the  formation  of  a 
distinct  pelvic  tumor.  The  rupture  not  infrequently  occurs  while  the  patient  is 
lying  in  bed ;  in  other  cases  the  immediate  cause  of  the  rupture  seems  to  be 
some  exertion,  such  as  lifting  or  reaching  overhead,  as  in  hanging  up  clothes,  or 
in  working  in  a  garden. 

In  some  instances  the  immediate  loss  of  blood  is  so  great  that  the  patient 
falls  to  the  floor  unconscious  as  suddenly  as  if  shot. 

The  anemia  varies  from  a  slight  blanching  to  a  deadly  pallor.  The  col- 
lapsed, anxious  appearance,  the  thready  pulse,  and  the  extreme  pain  and  abdomi- 
nal tenderness  are  characteristic,  even  though  there  is  no  tumor  or  perceptible 
uterine  enlargement. 

On  making  a  pelvic  examination,  the  uterus  may  be  found  enlarged  and  the 
cervix  softened.  If  the  blood  is  fluid  and  free  in  the  abdomi- 
nal cavity,  it  may  not  be  possible  to  feel  it,  but  in  almost  all  cases  a  mass 
of  somewhat  indefinite  outlines  and  peculiar  consistence  can  be  detected  pos- 
terior to  and  at  one  side  of  the  uterus. 

"When  a  succession  of  hemorrhages  occurs  at  intervals  of 
a  few  hours,  several  days,  or  even  some  weeks  apart,  each  one  is  marked  by  a 
repetition  of  the  symptoms  described.  Sometimes  the  first  attack  is  just  severe 
enough  to  constitute  a  warning,  and  the  later  attacks  increase  in  severity. 

After  some  days  or  weeks  have  elapsed  the  coagula  in  the  pelvis  become 
walled  off  by  adhesions  among  the  intestines,  and,  with  the  absorption  of  some 
of  the  fluid  elements,  the  pelvic  mass  assumes  a  doughy  consistence  ;  it  is  dis- 
tinctly impressible  by  the  finger,  although  no  pit  is  left  behind,  and  it  conveys 
a  sense  of  indistinctnessof  outline  which  is  quite  pe- 
culiar. 

A  rectal  examination  will  sometimes  show  the  jiresence  of  clots  of  l)lood  in 
the  pelvis,  which  can  be  felt  breaking  up  under  tlie  finger. 

When  the  pregnancy  is  a d  v a n c e d  the  difficulty  is  not  so  much 
the  diagnosing  of  a  pregnancy  as  the  determination  whether  it  is  extra-uterine 
or  intra-uterine  ;  the  diagnosis  is  best  made  by  putting  the  patient  under  anes- 
thesia and  grasping  the  cervix  with  forceps  and  cai-efully  drawing  down  the 
uterus  toward  the  vaginal  outlet  while  palpating  its  outlines  through  the  rectum. 
If  the  entire  uterus  can  be  distinctly  outlined  in  this  way  the  ovum  is  clearly 
extra-uterine.  Error  is  far  more  apt  to  arise  from  mistaking  a  noi-mal  preg- 
nancy for  an  extra-uterine  pregnancy.  "When  the  amniotic  fluid  is  scant  and 
the  utenne  walls  are  thinned  out  almost   to   the  consistence  of  wet  blotting 


448  EXTRA-UTEKINE    PREGNANCY. 

paper,  the  impression  of  an  extra-uterine  pregnancy  conveyed  by  palpating 
through  thin  abdominal  walls  may  be  almost  irresistible.  A  skillful  vaginal  and 
bimanual  examination  will,  however,  correct  the  diagnosis.  It  must  never 
be  forgotten  that  the  patient  may  present  an  extra-uter- 
ine and  an  i n t r a -u t e r i n  e  pregnancy  at  the  same  time.  The 
milk  in  the  1  jreasts  and  the  1  i  n  e  a  nigra  are  found  in  the  extra-uterine  as 
well  as  in  a  normal  pregnancy. 

A  pregnancy  in  one  horn  of  a  bicornute  uterus  will  be 
distinguished  by  the  lop-sided  shape  of  the  enlarged  unimpregnated  horn,  as  well 
as  by  the  low,  i3road  connection  of  the  sac  with  the  cervical  end  of  the  uterus. 

An  error  in  the  diagnosis  of  a  ruptured  extra-uterine  pregnancy  in  the  early 
months  is  most  likely  to  occur  in  the  case  of  a  pelvic  abscess.  In  one  of  my 
cases  at  the  Johns  Hopkins  Hospital  there  was  cessation  of  menstruation  and  an 
irregular  return,  with  sudden  severe  pain  in  the  right  side,  followed  by  similar 
attacks  ;  the  patient  was  compelled  to  go  to  bed,  and  showed  a  decided  pallor. 
There  was  a  slight  elevation  of  the  temperature.  The  examination  revealed  an 
irregular,  tender  mass  to  the  right  of  the  uterus,  free  from  the  density  usually 
found  in  pelvic  abscess ;  a  diagnosis  of  extra-uterine  pregnancy  was  made,  but 
the  operation  proved  the  case  to  be  one  of  simple  pelvic  abscess. 

It  must  be  borne  in  mind  that  a  good  percentage  of  the  cases  of  rup- 
tured extra-uterine  pregnancy  sooner  or  later  become  in- 
fected and  form  a  pelvic  abscess,  in  which  case,  of  course,  both  con- 
ditions exist  simultaneously.  The  presence  of  some  old  blood  clots  evacuated 
with  the  pus  will  at  once  suggest  the  nature  of  the  original  affection,  and  the 
microscopical  examination  of  the  villi  will  set  the  diagnosis  at  rest. 

A  remarkable  and,  I  believe,  a  unique  case  was  one  in  which  one  of  my 
patients  suffering  from  membranous  dysmenorrhea  passed  a  complete 
cast  of  the  uterine  cavity ;  the  next  month  she  became  pregnant  in  the  uterine 
tube,  and  again  passed  a  perfect  decidual  cast  of  the  uterus ;  both  of  these  casts 
were  kept  and  put  into  my  possession.  She  was  not  conscious  of  any  ab- 
normality in  her  condition  until  she  suddenly  felt  an  agonizing  pain  in  the 
lower  abdomen  and  fell  to  the  floor  in  the  bathroom  ;  these  attacks  of  pain 
were  repeated  with  decided  temperature  elevation  and  a  marked  pallor  devel- 
oped. At  the  examination  I  found  the  uterus  embedded  in  hard,  irregular, 
inflammatory  masses  filling  the  pelvis,  in  no  way  resembling  the  ordinary  type 
of  an  early  ruptured  extra-uterine  pregnancy.  The  diagnosis  of  extra-uterine 
pregnancy  was,  however,  made  from  the  history  and  confirmed  by  operation. 

Diagnosis  of  Interstitial  Pregnancy. — The  diagnosis  in  a 
case  of  interstitial  pregnancy  may  offer  considerable  difiiculties.  I  have  fre- 
quently observed  a  peculiar  condition  of  the  uterus  in  the  early  months  of  a 
pregnancy  terminating  normally,  which  might  easily  be  mistaken  for  an  inter- 
stitial extra-uterine  pregnancy. 

In  each  instance  the  softening  and  the  enlargement  of  the  uterus  was  con- 
fined to  one  of  the  apices,  leaving  the  rest  of  the  uterine  body  firm  and  un- 
changed.    The  impression  conveyed  to  the  examining  finger  was  that  of  a  cyst 


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DESCRIPTION  OF  PLATE  XXIII. 

DIAGNOSIS  OF  EXTRA-UTERINE   PREGNANCY  BY  MICROSCOPIC  EXAMINATION — DEMON- 
STRATION OF  BLOOD  CLOT,   DECIDUAL  CELLS,  AND  PLACENTAL  VILLL 

Fig.  1  (Gyn.  Path.  No.  417,  Tubal  Pregnancy)  is  a  cross-section  of  a  tube  about 
1'5  centimeter  from  its  uterine  extremity.  Attached  to  the  outer  surface  are  two 
vascular  adhesions ;  the  muscular  coats  are  somewhat  thickened ;  the  tubal  folds  in 
many  places  are  normal,  but  several  of  them,  especially  those  to  the  left  of  the  cen- 
ter, have  markedly  engorged  blood  vessels,  as  indicated  by  the  red  coloring,  while 
lying  free  between  the  folds  is  considerable  blood.  Below  and  just  to  the  left  of 
the  center,  and  lying  free  in  the  tube,  is  a  pear-shaped  body ;  the  base  of  this  is  com- 
posed of  blood  divided  oflp  into  segments  of  variable  size ;  the  upper  part  is  composed 
of  convoluted  folds.    The  intei*est  centers  around  this  pear-shaped  body. 

Fig.  2  is  a  further  enlargement  of  the  upper  part  of  the  pear-shaped  body  with  the 
adjoining  tubal  folds.  The  fold  above  and  to  the  left  shows  an  injection  of  its  ves- 
sels, while  the  stroma  at  the  base  of  the  three  folds  is  rarefied  and  filled  by  a  homo- 
geneous vacuoled  substance  that  takes  the  eosin  stain.  This  is  probably  due  to  a  dila- 
tation of  the  lymph  channels.  A  similar  condition  is  present  in  the  fold  immediately 
above  the  pear-shaped  body.  The  remaining  folds  are  normal,  and  all  have  a  normal 
epithelial  covering. 

The  pear-shaped  body  consists  of  an  outer  and  solid  portion  and  an  inner  portion 
composed  almost  entirely  of  blood.  This  outer  portion  consists  of  a  myxomatous  tis- 
sue, and  presents  a  convoluted  or  wavy  outline ;  and  the  outer  surface  is  covered  by 
two  layers  of  cells,  an  inner  and  well-defined  layer,  with  round  or  oval  vesicular 
nuclei,  and  an  outer  layer,  where  the  protoplasm  of  one  cell  can  not  be  distinguished 
from  that  of  the  surrounding  ones ;  in  other  words,  the  protoplasm  of  the  outer  row 
forms  a  regular  ribbon.  The  nuclei  are  round  or  oval  and  stain  very  deeply.  This  is 
the  syncytium.  Above,  and  to  the  right,  some  of  these  folds,  which  are  the 
young  placental  villi,  have  been  cut  transversely,  and  the  outer  row  of  cells  is 
tending  to  form  the  so-called  "  placental  giant "  cells.    No  trace  of  the  fetus  was  found. 


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X120  Fig  2. 

MBrodel.fec  DihLPran^iCo.Boatw.usA 


MORTALITY.  449 

from  5  to  10  centimeters  in  diameter,  situated  up  in  one  corner  of  tlie  uterus. 
A  remarkable  feature  of  this  form  of  pregnancy  is  the  fact  that  it  is  often  asso- 
ciated with  more  or  less  severe  pain. 

In  one  case  under  anesthesia  the  right  side  of  the  uterus  in  its  upper  half  was 
converted  into  a  fluctuating  sac  10  centimeters  in  diameter,  while  it  was  sur- 
rounded on  the  left  side  and  below  by  firm  uterine  tissue ;  the  distinction 
between  the  sac  and  the  rest  of  the  uterus  was  so  well  marked  that  under 
anesthesia  the  tumor  was  thought  to  be  situated  in  the  tube  close  to  the  uterus, 
and  after  a  most  careful  bimanual  examination  I  concluded  that  there  was  a  dis- 
tinct but  narrow  interval  between  them.  This  patient  had  suffered  the  most  in- 
tense pain  throughout  her  pregnancy.  On  opening  the  abdomen  I  found  a  large 
spherical  reddish  sac  bulging  out  from  the  left  cornu  of  the  uterus,  soft  and  fluc- 
tuating, and  in  one  place  above  and  in  front  there  was  an  area  of  the  sac,  3x3 
centimeters  in  size,  so  thin-  as  to  be  almost  transparent.  The  tubes  and  the 
ovaries  were  normal.  I  closed  the  abdomen  after  passing  a  sound  into  the  uterus 
and  rupturing  the  membranes,  and  the  ovum  was  discharged  soon  after  by  the 
vagina. 

In  six  other  cases  I  have  been  able  to  diagnose  this  condition,  and  in  each 
one  the  sequel  has  proved  the  correctness  of  the  diagnosis.  In  one  instance  a 
physician  brought  his  ^vife  from  Iowa  for  operation,  with  the  diagnosis  of  extra- 
uterine pregnancy ;  she  had  a  cystic  tumor  growing  in  the  left  upper  cornu 
uteri,  representing  a  five  months'  pregnancy,  while  the  rest  of  the  uterus  was 
firm  and  unchanged.  Her  suffering  had  been  so  great  as  to  confine  her  almost 
constantly  to  bed.  I  gave  my  opinion  that  the  pregnancy  was  intra-uterine  of 
this  peculiar  form,  and  would  terminate  normally ;  it  did  so  four  months 
later. 

If  my  interpretation  of  these  cases  is  correct,  this  condition  affords  an  ex- 
planation of  some  of  the  cases  reported  as  extra-uterine  pregnancy  becoming 
intra-uterine  with  or  without  the  assistance  of  the  electric  current.  On  the  other 
hand,  the  objection  may  be  offered  that  these  cases  are  in  reality  interstitial  preg- 
nancies with  an  ovum  simply  lodged  very  near  to  the  uterine  cavity  and  becom- 
ing intra-uterine  with  the  increase  in  the  size  of  the  ovum,  as  interstitial  preg- 
nancies not  infrequently  do. 

The  characteristics  of  this  peculiar  form  of  apical  pregnancy  are — 

That  one  apex  or  one  half  of  the  uterus  enlarges  and  softens  without  the 
participation  of  the  rest  of  the  organ. 

That  this  is  most  marked  in  the  early  months,  but  observable  as  late  as  the 
fifth  or  sixth. 

That  the  pregnancy  is  painful,  the  patient  often  complaining  of  an  amount 
of  suffering  never  felt  before  during  other  normal  pregnancies. 

That  the  pregnancy  terminates  normally. 

Mortality. — The    mortality  of   extra-uterine    pregnancy  when    uninterfered 

with  is  68-8  per  cent,  according  to  Schauta,  reckoned  on  a  basis  of.  two  hundred 

and  forty-one  cases.     This  estimate  does  not  include  those  early  cases  in  which  a 

rupture  takes  place  without  severe  symptoms  and  the  patient  complains  only  of 

71 


450  EXTRA-UTERINE    PREGNANCY. 

colic  and  goes  to  bed  for  a  short  time,  exhibits  no  pallor,  and  the  blood  is  soon 
absorbed. 

Veit  reckons  the  mortality  in  cases  in  which  a  hematocele  has  formed  as  high 
as  from  25  to  28  per  cent. 

In  the  early  months  the  death  is  almost  invariably  due  to  hemorrhage ;  later 
it  is  caused  by  a  septic  peritonitis  or  the  rupture  of  the  sac  into  the  bowels. 

Treatment . — On  account  of  the  imminent  danger  to  the  life  of  the 
mother,  the  extra-uterine  pregnancy  in  the  early  months  must  be  looked  upon 
much  as  a  malignant  growth  (Werth),  and  it  is  only  from  the  seventh  month  of 
pregnancy,  when  the  child  is  viable,  that  it  has  any  claims  to  consideration. 

The  proposal  to  defer  the  active  treatment  of  an  extra-uterine  pregnancy  in 
its  early  stages  in  the  interests  of  the  child  is  simple  sentimentality.  A.  Martin 
has  shown  that  36*9  per  cent  out  of  two  hundred  and  sixty-five  cases  of  extra- 
uterine pregnancy  recovered  under  an  expectant  plan  of  treatment,  but  that  76*T 
per  cent  out  of  five  hundred  and  fifteen  cases  recovered  under  operative  treat- 
ment ;  in  the  hands  of  a  good  operator  the  mortality  would  not  exceed  five  or 
six  per  cent. 

The  plans  of  treatment  differ  so  widely  early  and  late  in  the  pregnancy  that 
I  shall  deal  with  them  separately. 

In  the  first  six  months  of  pregnancy  the  one  important  practical  considera- 
tion is  how  best  to  remove  the  abnormal  products. 

In  the  early  months,  when  about  76  per  cent  of  the  cases  are  observed,  the 
plan  of  treatment  is  either  by  an  abdominal  or  by  a  vaginal  section,  the  former 
enucleating  and  the  latter  draining  the  sac. 

Celiotomy. — The  operation  differs  widely  in  its  details  according  to  the  ana- 
tomical relations  and  the  complications  found ;  the  fetus  and  the  sac  may,  for 
example,  develop  in  the  tube  out  in  the  direction  of  the  abdominal  cavity,  and 
are  therefore  pedunculate,  or  they  may  develop  within  the  layers  of  the  broad 
ligament ;  again  the  sac  may  have  ruptured  or  may  be  suppurating. 

The  operation  is  either  radical,  removing  the  fetus,  placenta,  membranes,  and 
sac,  or  it  is  conservative,  evacuating  the  sac  of  its  contents  and  removing  as  much 
as  possible  of  the  extra vasated  blood  without  sacrificing  either  the  tube  or  the 
ovary. 

The  general  principles  of  the  radical  operation  are 
these:  An  abdominal  incision.  Separation  of  adhesions  enveloping  the  sac. 
Removal  of  blood,  fetus,  membranes,  placenta,  and  sac.  Checking  of  all 
hemorrhage.  Complete  closure  of  the  abdomen  without  drainage  in  aseptic 
cases. 

"When  the  sac  is  ruptured  and  clots  have  formed,  drainage  by  the  vagina 
without  opening  the  abdomen,  as  well  as  in  suppurating  cases. 

In  all  cases  of  active  hemorrhage  from  any  part  of  the  sac  the  cardinal  rule 
is  to  open  the  abdomen  at  once  and  to  control  the  uterine  and  ovarian  arteries 
at  points  beyond  the  sac. 

Active  hemorrhage  from  the  sac  wall  has  been  temporarily  controlled  by 
compression  of  the  abdominal  aorta. 


Fig.  527. — E.ytra-uterine  Pregnancy;  Tubal  Abortion. 

The  bleedincr  is  checked  by  a  large  coa^ulum  distending  and  thinning  out  the  tube  ;  the  liinhriated  open- 
ing is  greatly  distended,  but  tlie  greater  diameter  of  the  clot  in  the  ampulla  prevents  its  escape.  Wall  of 
tube  averaging  one  millimeter  in  thickness.     Operation.     Kecovcry,  July  7,  Ib'Jti.     Natural  size. 


FlO.    528. — CoAOlI.UM    TIKNED    OIT. 

Showing  a  cast  of  the  tube  extending  up  into  the  isthmus.     On  its  surface  lies  the  foetus.     Natural  size. 


CELIOTOJIY.  451 

When  a  diagnosis  of  an  unruptured  extra-uterine  sac  is 
made,  the  ojDeration  should  be  performed  with  as  Httle  delay  as  possible.  The 
technique  of  such  an  operation  differs  but  little  from  that  of  the  extirpation  of 
an  ovarian  tumor  or  a  hydrosalpinx.  The  adhesions,  if  they  exist,  are  usually 
not  difficult  to  separate ;  care  must  be  taken  not  to  rupture  the  sac  for  fear  of 
profuse  hemorrhage  ;  if  this  accident  occurs,  or  if  the  sac  is  so  thin  as  to  make 
rupture  almost  certain,  it  is  well  as  a  preliminary  step  to  clamp  and  control  the 
ovarian  vessels  out  at  the  pelvic  brim  and  the  uterine  vessels  at  the  cornu,  in 
this  way  controlling  the  circulation  of  the  sac,  which  is  then  leisurely  removed, 
the  vessels  all  ligated,  the  pedicle  dropped,  and  the  abdomen  closed  without  a 
drain. 

The  patient  should  be  kept  absolutely  quiet  and  stimulated,  and  in  all 
cases  of  anemia  half  a  liter  of  normal  salt  solution  should 
be  injected  into  the  cellular  tissue  under  each  breast.  The 
importance  of  this  injection  can  not  be  overestimated ;  the  collapsed  patient 
rapidly  revives  as  the  vessels  fill  with  the  solution,  and  the  pulse  gaining  in 
volume  diminishes  in  frequency.  Patients  have  been  successfully  operated  upon 
in  profound  collapse,  but  I  would  rather  wait  a  few  hours,  in  some  cases,  if  there 
are  any  decidedly  encouraging  signs  of  improvement,  to  gain  the  maximum  effect 
from  stimulation,  and  then  do  the  operation. 

The  duration  of  the  anesthesia  should  be  as  short  as 
possible. 

In  preparing  the  field  of  operation  the  assistants  must 
not  make  much  pressure  at  the  vaginal  vault  or  on  the 
lower  abdomen   for  fear  of  exciting  more  hemorrhage. 

A  moderate  elevation  of  the  pelvis  is  an  advantage  dur- 
ing the  operation  in  keeping  the  blood  more  in  the  upper  part  of  the  body  and 
in  the  heart. 

The  first  indication  of  the  hemorrhage  may  be  found  in  the  discoloration  of 
the  skin  above  the  symphysis,  or  in  the  greenish  and  bluish  color  of  the  fat  seen 
on  making  the  incision,  in  older  cases ;  in  a  recent  case  the  subperitoneal  fat 
may  be  stained  dark  by  the  extravasated  blood,  or  it  may  be  seen  through  the 
peritoneum  before  opening  it. 

As  a  rule,  when  the  peritoneum  is  opened,  the  liquid  blood  commences  to 
flow  out,  and  the  patient  should  be  let  down  almost  to  a  level  to  facilitate  the 
evacuation.  I  have  seen  the  blood,  when  extravasated  in  large  quantities,  under 
such  tension  that  it  spurted  up  several  feet  into  the  air  as  soon  as  the  peritoneum 
was  incised. 

A  free  incision  should  be  made  from  10  to  15  centimeters  long,  so  as  to  get 
at  the  disease  with  as  little  delay  and  difficulty  as  possible.  The  blood  should 
be  removed  by  handfuls  or  with  a  ladle,  the  operator  all  the  while  keeping  his 
eyes  directed  into  the  pelvis  to  note  whether  there  is  any  active  hemorrhage 
going  on  ;  if  there  is  none,  he  may  carefully  clean  the  field  and  expose  the 
structures  before  proceeding  to  enucleate  them.  If,  however,  there  is  any  evi- 
dence of  active  bleeding,  as  shown  by  bright  blood  welling  up  in  the  pelvis  as 


452 


EXTRA-UTERIKE   PREGNAXCY. 


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Fig.  529. — Extra-uterine  FREGNA]:fCY  (Eight),  with  Tubal  Abortion. 

Tlie  inside  of  the  tube  is  covered  with  laminated  blood  clots,  some  of 
which  adhere  to  the  wall,  wliich  averages  two  millimeters  in  thickness. 
The  peritoneal  surface  of  the  tube  is  coated  with  cylindrical  epithelium. 
No  placental  villi  found.  Corpus  luteum  in  same  ovary.  May  28,  1894. 
Path.  No.  315.     Natural  size. 


fast  as  the  clots  are  ladled  out,  the  operator  should  not  delay  in  order  to  get  a 

better  exposure,  but  should  at  once  thrust  his  hand  down  into  the  pelvis  in  the 

midst  of  the  clots  and  grasp  the  uterus.     Taking  the  uterine  body  as  a  guide, 

he  then  feels  out  onto 
broad  ligament 
the  tubes  on 
one  side  and  on  the 
other,  until  he  de- 
tects the  extra-uterine 
mass ;  this  is  then 
grasped  boldly  and 
drawn  up  and  strong 
clamps  applied,  by 
touch  alone,  on 
uterine  side  and 
the  side  toward 
brim  of  the  pelvis 
the  event  of  uncer- 
tainty, two  clamps 
should  be  put  on  each 
side,  one  at  each  uter- 
ine cornu  and  one  at 

each  pelvic  brim.     After  controlling  the  circulation  in  this  way,  the  rest  of  the 

enucleation  may  be  conducted  more  leisurely.     Before  the  patient  is  taken  from 

the  table  a  hot    stimulating    rectal    enema    should    be    given, 

with   the   pelvis  well   elevated,  containing  thirty  grains  of  carbonate 

of  ammonia,  three  ounces  of  brandy,  and  three  eggs  beaten 

up  in  a  liter  of  normal  salt  solution. 

All   blood  clots  should  be  carefully  laid  in  one  dish 

together,  and  all  blood  washed  out  of  the  abdominal  cavity 

should  be  kept  and  a  careful  search  made  for  the  fetus. 

In  the  majority  of  the  very  early  cases  this  will  not  be 

found,  being  doubtless  removed  by  the   phagocytes ;   in 

Bome  cases,  however,  a  minute  body,  best  recognized  by  a 

black  speck,  the  eye,  such  as  is  shown  in  Fig.  52Y,  will  be 

found  ;  in  other  instances  a  little  bit  of  flesh  with  a  black 

spot  and  some  broken  bits  will  represent  the  tender  dimin- 
utive fetus  as  seen  in  Fig.  530. 

When  the  sac  is  walled  off   by  adhesions  there  is  no 

active  hemorrhage,  and  the  first  efforts  of  the  operator 

after  opening  the  abdomen  will  be  directed  toward  releas- 

iufir  the  adherent  omentum  and  adherent  bowel  until  the 

concealed  sac  and  coagula  are  set  free  for  enucleation  ;  in 

just  this  class  of  cases,  however,  I  desire  to  recommend  a  conservative  plan  of 

treatment,  and  that  is — 


Fig.  530. — Operation  fob 
Ruptured  Extra-utee- 
iNE  Pregnancy. 

Showing  the  bits  of  the 
little  fetus  removed  and 
found  concealed  in  the 
clots.  The  means  of  rec- 
ognizing the  head  was  the 
little  piece  of  flesh  with  a 
black  spot  indicating  the 
eye.  May  9,  189U.  Natu- 
ral size. 


VAGIXAL   INCISION"   AND    DKAINAGE.  453 

Vaginal  Incision  and  Drainage.  — T his  is  the  best  plan  in  all  old 
cases  where  there  have  been  repeated  hemorrhages  with 
the  formation  of  a  well-defined  immovable  mass  which 
can  be  felt  through  the  vaginal  vault.  They  are  the  cases  which 
usually  come  to  the  clinic  with  a  history  of  pains  spreading  out  over  several 
weeks  or  some  months.  Sometimes  the  accumulation  bulges  well  down  through 
Douglas's  cul-de-sac  into  the  vagina,  but  is  oftener  felt  best  through  the  rec- 
tum, distending  one  side  of  the  posterior  pelvis  and  extending  across  the  median 
line.  The  vaginal  incision  practiced  in  such  cases  is  quite  different  from  the 
similar  procedure  recommended  for  the  extraction  of  a  fetus  lodged  in  the  pelvis 
in  the  later  months  of  extra-uterine  pregnancy,  or  for  the  evacuation  of  a  sup- 
purating sac. 

The  advantages  of  vaginal  drainage  are  : 

1.  The  tubes  and  ovaries  are  both  preserved. 

2.  By  this  avenue  the  coagula,  escaped  membranes,  placenta,  and  fetus,  if 
found,  are  removed  usually  without  opening  the  general  peritoneal  cavity. 

3.  The  vaginal  method  is  free  from  danger,  if  the  operator  is  prepared  to 
open  the  abdomen  at  once  in  case  of  unexpected  hemorrhage, 

4.  It  is  quickly  performed,  consuming  no  time  in  making  and  closing  the 
incision. 

5.  It  avoids  dealing  with  such  a  serious  complication  as  intestinal  adhesions. 
The  dangers  of  the  vaginal  incision  are  : 

1.  Active  uncontrollable  hemorrhage  from  the  sac. 

2.  The  risk  of  opening  an  adherent  intestine  or  of  puncturing  the  rectum. 

3.  The  possibility  of  the  sac  wall  breakmg  down  and  so  opening  up  an  avenue 
for  the  infection  of  the  peritoneal  cavity. 

Out  of  twelve  cases  treated  in  this  way  at  the  Johns  Hopkins  Hospital  I  was 
forced  to  open  the  abdomen  immediately,  in  one  instance,  in  order  to  check  a 
hemorrhage  from  the  sac  which  started  up  as  soon  as  I  had  cleaned  out  the 
coagula,  and  which  persisted  in  oozing  through  into  the  vagina  in  8j)ite  of  the 
pressure  of  a  carefully  applied  pack.  Prof.  M.  D.  Mann,  of  Buffalo,  has  lost  a 
life  under  similar  circumstances,  in  which  the  abdomen  was  not  opened. 

Two  of  these  cases  were  treated  by  a  combined  abdominal  and 
vaginal  operatio n — that  is  to  say,  after  the  abdomen  had  been  opened 
the  adhesions  were  found  to  be  so  numerous  that  the  enucleation  bid  fair  to  be 
one  of  unusual  risk  to  life,  so  the  sac  was  evacuated  and  drained  through  the 
vagina,  all  the  while  conducting  the  operation  under  the  guidance  of  the  eye 
and  with  a  hand  within  the  abdomen  defining  the  upper  limits  of  the  sac  and 
protecting  the  abdomen  from  intrusion  from  below.  In  this  way  a  complete 
evacuation  was  secured  with  good  drainage  into  the  vagina ;  the  abdomen  was 
closed  without  a  drain  and  an  uninterrupted  recovery  followed. 

I  have  seen  a  sac  opened  through  the  vagina  and  emptied  of  its  contents 
close  down  completely  without  suppuration. 

Method  of  O  p  e  r  a  t  i  n  g. — X  thorough  bimanual  examination  should 
be  made  beforehand  both  by  vagina  and  by  the  rectum,  if  necessary  under 


454:  EXTRA-UTERIIfE    PREGNAXCY. 

anesthesia,  in  order  that  the  operator  may  know  exactly  the  relations  of  the  sac 
to  the  uterus,  rectum,  broad  ligaments,  and  Douglas's  poncli.  All  preparations 
should  be  made  for  an  abdominal  operation  in  case  it  should  become  necessary 
on  account  of  hemorrhage.  After  properly  cleansing  the  parts,  the  posterior 
vaginal  wall  is  retracted  and  the  posterior  Up  of  the  cervix  is  caught  with  tenac- 
ulum forceps  and  drawn  a  little  downward  and  forward  so  as  to  give  a  wider 
space  between  the  rectum  and  cervix  for  the  puncture  or  incision. 

If  the  sac  is  at  all  prominent,  or  can  be  distinctly  felt  in  the  vaginal  vault 
behind  the  cervix,  the  operator  simply  marks  with  his  index  finger  the  point 
for  puncture  on  the  median  line,  two  or  three  centimeters  back  of  the  cervix ; 
then  introducing  a  pair  of  sharp-pointed  straight  scissors  to  that  point,  he 
pushes  them  boldly  through  the  peritoneo-vaginal  septum,  at  the  same  time 
giving  the  blades  an  upward  turn  so  as  to  keep  them  in  the  direction  of  the  axis 
of  the  pelvis.  If  the  pelvic  curve  is  not  followed,  there  is  risk  of  the  scissors 
transfixing  the  sac  and  perforating  the  rectum  posterior  to  it. 

When  the  lower  limits  of  the  sac  are  not  well  defined,  it  is  a  good  rule  to 
protect  the  bowel  by  keeping  the  middle  finger  in  the  rectum,  touching  the 
lower  border  while  the  index  finger  of  the  same  hand  rests  upon  it  in  the  vagina ; 
the  scissors  controlled  in  this  way  will  easily  keep  the  right  direction. 

As  soon  as  the  points  penetrate  the  sac,  as  shown  by  a  lessened  resistance,  if 
the  blades  are  spread  a  little  apart,  some  dark  blood  will  be  seen  to  ooze  out  into 
the  vagina,  indicating  the  correctness  of  the  diagnosis. 

By  withdrawing  the  blades  open,  the  hole  in  the  vault  is  torn  large  enough 
to  let  in  the  index  finger  for  the  purpose  of  palpating  the  lower  part  of  the  sac ; 
if  this  is  free  a  larger  pair  of  scissors  is  introduced  and  withdrawn  open,  fol- 
lowed by  uterine  dilators.  In  this  way  a  transverse  opening  is  made  in  the  vagi- 
nal vault  2*5  to  3  centimeters  in  breadth.  The  bleeding  from  the  torn  edges  of 
the  opening  has  never  been  great  enough  to  render  it  necessary  to  apply  a 
ligature  or  suture,  or  to  make  it  advisable  to  use  a  cautery  knife  in  making  the 
opening. 

The  clots  which  begin  to  escape  at  once  must  now  be  evacuated  by  introduc- 
ing the  first  and  second  fingers  and  hooking  them  down.  The  other  hand,  mak- 
ing counter-pressure  above,  greatly  aids  the  fingers  working  in  the  sac  by  bring- 
ing all  parts  of  its  walls  successively  within  reach.  Only  gentle  force  must  be 
used  in  detaching  clots  from  the  walls.  After  a  portion  of  the  coagula  has  been 
removed  the  escape  of  the  remainder  will  be  aided  by  washing  out  the  sac  freely 
with  warm  water  and  using  the  blunt  round  point  of  the  glass  nozzle  carefully 
over  the  inner  walls. 

In  the  case  of  a  tubal  abortion,  I  have  been  able  to  recognize  the  condi- 
tion by  introducing  a  finger  into  the  end  of  the  tube,  as  well  as  by  several 
large  clots  with  a  peculiar  rounded-ofE  surface  which  formed  a  cylindrical  mass 
when  put  together.  When  the  evacuation  is  complete  the  entire  inner  surface 
of  the  sac  should  be  explored  and  its  relations  to  the  uterus,  the  pelvic  walls, 
and  its  inequalities  investigated ;  if  possible,  the  oj)posite  side  should  be  felt 
also. 


TREATMENT    OF    IMTRALIGAMENTART    EXTRA-UTERINE    PREGNAN"CY.         455 

The  gauze  drain  is  now  put  in.  A  long  piece  of  sterilized  washed- 
out  iodoform  gauze,  aljout  6  centimeters  wide,  is  slowly  pushed  up  into  the  sac 
with  the  packer,  until  the  sac  is  loosely  filled  and  the  opening  into  the  vaoina 
kept  wide  apart. 

A  loose  pack  is  left  in  the  vagina  and  the  patient  is  then  put  to  bed.  The 
pack  may  be  left  in  place  for  from  three  to  five  or  seven  days,  when  it  is  then 
taken  out  and  a  fresh  pack  put  in.  As  soon  as  there  is  any  suppuration  or  odor- 
ous discharge  the  pack  must  be  removed  and  the  sac  washed  out  daily  with  a 
saturated  boric-acid  solution  or  a  2  per  cent  carbolic-acid  solution,  and  just 
enough  gauze  put  back  in  the  opening  to  keep  it  froni  closing  rapidly.  In  the 
course  of  two  or  three  weeks  the  whole  sac  has  contracted  down  to  the  opening 
and  closes  spontaneously. 

In  one  of  my  cases  where  the  irrigation  was  managed  by  the  nurse,  the  point 
of  the  douche  nozzle  perforated  the  sac  wall  and  several  of  the  douchings  for 
two  days,  of  a  liter  each  of  the  boric-acid  solution,  were  run  into  the  peritoneal 
cavity. 

The  patient  was  brought  onto  the  operating  table  a  second  time  in  a  col- 
lapsed condition,  under  the  impression  that  she  had  a  concealed  hemorrhage ; 
the  abdomen  was  opened,  a  large  quantity  of  milky  fluid  found  and  washed  out, 
and  drains  inserted  in  the  median  line  and  in  each  flank,  as  well  as  in  the  vagina, 
and  she  made  a  good  recovery. 

In  a  similar  case.  Prof.  Zweifel  was  not  so  fortunate  (see  Arch.f.  Gyn.,  Bd. 
xli,  p.  1).  Here  the  assistant  pushed  the  irrigating  tube  into  the  pei'itoneal  cavity 
to  one  side  of  the  cyst,  and  the  patient,  with  the  sac  already  infected,  died  of 
a  violent  septic  peritonitis. 

Kone  of  the  cases  operated  upon  in  this  way  in  the  Johns  Hopkins  Hospital 
died.  I  lost  one  case  outside,  for  which  the  operation  was  in  no  way  responsi- 
ble. The  patient  had  a  nephritis  with  incontinence  of  urine,  and  had  lain  for 
six  days  in  a  comatose  state,  with  contracted  pupils  and  closed  eyes,  moaning 
and  crying  out  in  an  inarticulate  way.  She  had  constant  elevation  of  tempera- 
ture— from  99°  to  101°  F.  By  vaginal  puncture  almost  a  liter  of  clots  was 
removed  with  a  quantity  of  liquid  blood.  The  peritoneal  cavity  was  not  opened. 
The  sac  was  drained  with  gauze,  and  she  was  put  to  bed  in  the  same  condition  as 
when  she  was  lifted  onto  the  table.  The  nephritis  advanced,  and  she  died  five 
days  later,  wnth  a  flat  abdomen  and  without  any  signs  of  a  local  reaction  follow- 
ing the  operation.  Such  a  history  is,  in  fact,  eminently  calculated  to  demon- 
strate the  advantages  of  the  operation  by  the  vaginal  route,  for  the  patient  could 
not  have  survived  an  abdominal  operation,  and  if  she  was  to  be  given  any  chance 
at  all  for  her  life  it  must  have  been  by  some  such  simple  way  as  this. 

The  average  age  in  the  eleven  cases  was  twenty-nine  years,  and  four  patients 
had  never  borne  a  child.  In  two  instances  the  vagina  was  opened  and  the  sac 
drained  after  opening  the  abdomen. 

Treatment  of  Intraligamentary  and  Pseudo-intraligamentary  Extra-uterine  Preg- 
nancy.— True  intraligameutary  extra-uterine  pregnancy  is  rare,  as  1  have  stated  ; 
most  cases  called  intraligameutary  are  in  reality  pseudo-intraHgamentary. 


456  EXTRA-UTEEIlSrE   PREGNANCY. 

The  proper  mode  of  treatment  in  these  cases  is  to  evacuate  and  drain  the  sac 
extraperitoneally,  either  by  the  vagina  or  above  Poupart's  ligament.  If  the 
peritoneum  is  opened  ^vith  a  view  to  extirpating  the  sac,  and  it  is  then  found 
broad-based  and  sessile  on  the  pelvic  floor  or  lifting  up  the  peritoneum  of  the 
anterior  abdominal  wall,  the  evacuation  should  be  by  the  vagina,  if  the  sac  is 
prominent  enough  to  be  easily  felt  there.  When  the  sac  elevates  the  peritoneum 
of  the  anterior  abdominal  wall  so  as  to  be  easily  accessible  from  the  front,  an 
incision  should  be  made  just  above  Poupart's  ligament,  the  peritoneum  lifted  up, 
the  sac  opened  and  cleared  out,  and  a  gauze  drain  inserted. 

If  the  abdomen  has  been  opened,  these  manipulations  are  all  easily  made 
under  the  guidance  of  the  hand,  within  the  abdomen,  without  opening  the  peri- 
toneum overlying  the  sac.  After  evacuating  and  draining  the  sac  the  abdominal 
incision  is  closed.  I  have  treated  two  cases  in  this  way  in  the  third  month  of 
pregnancy  without  sacrificing  any  of  the  pelvic  organs. 

Treatment  of  Advanced  Extra-uterine  Pregnancy. — In  advanced  extra-uterine 
pregnancy  the  treatment  will  differ  according  as  the  fetus  is  living  or  dead,  and 
the  operator  has  to  deal  with  a  placental  circulation  which  is  still  active,  or  with 
one  which  is  plugged  by  well-organized  thrombi.  So  long  as  the  circulation  in 
the  placenta  continues,  the  operation  may  be  full  of  danger  on  account  of  the 
excessive  hemorrhage  produced  by  every  effort  made  to  detach  the  placenta. 
When  the  placental  site  is  on  the  tubal  wall,  on  the  abdominal  wall,  on  the 
uterus,  or  on  the  broad  ligament,  it  may  be  possible  to  control  the  hemorrhage 
by  ligating  the  large  vessels  going  into  the  sac,  or  by  passing  ligatures  deeply 
into  the  surrounding  tissues  on  all  sides  of  the  site  of  attachment. 

If  the  danger  of  removal  of  the  entire  live  placenta  is  too  gi'eat,  owing  to  its 
widespread  attachment  over  the  intestines  and  the  large  vessels  going  to  it  which 
can  not  be  tied,  the  cord  is  simply  tied  as  short  as  possible,  and  an  extensive 
washed-out  iodoform  gauze  drain  packed  over  its  site ;  the  discharge  of  the  pla- 
centa then  takes  place  piecemeal  at  a  later  date.  But  the  danger  to  life  is  exces- 
sive on  account  of  the  j)ossible  infection  of  the  large  mass,  associated  with  the 
excessive  uncontrollable  secondary  hemorrhage  due  to  the  breaking  down  of  the 
recent  thrombi. 

The  attempt  has  been  successfully  made  of  tying  off  the  cord  and  closing  the 
abdomen  and  leaving  the  placenta  in,  and  trusting  to  the  aseptic  character  of  the 
operation  to  avoid  a  subsequent  infection. 

After  the  death  of  the  child  the  placental  circulation  still  continues  active, 
and  the  bruit  may  be  heard  for  a  period  of  one  or  two  weeks.  Unless  the  symp- 
toms are  urgent  it  is  better  in  such  cases  to  wait  several  weeks 
to  give  the  thrombi  a  chance  to  become  well  organized.  The 
detachment  of  the  placenta  will  not  then  be  associated  with  any  risk. 

If  the  child  is  viable  the  operation  should  be  performed 
without  waiting  for  the  pregnancy  to  complete  its  term,  as 
false  labor  may  set  in  at  any  time  and  the  child's  life  be  lost.  There  is  also 
the  farther  disadvantage  in  waiting,  that  with  the  absorption  of  the  liquor 
a  m  n  i  i  in  the  last  months  the  fetus  is  often  seriously  pressed  upon  by  surround- 


TREATMEXT   OF    ADVAXCED    EXTRA-UTERIXE    PREGNANCY.  457 

ing  parts,  tending  to  produce  deformity  and  to  interfere  mth  its  nutrition. 
Tliis  fact,  together  with  the  early  stage  at  which  many  of  the  fetuses  are  deliv- 
ered, accounts  for  the  excessive  mortaHty  among  the  extra-uterine  viable  fetuses. 

The  operation,  when  the  fetus  is  viable,  consists  in  the  most  painstaking  pre- 
liminary prejDarations  and  in  precautions  throughout  to  maintain  a  rigid  asepsis. 

I  would  insist  upon  the  operator  and  his  assistants  wearing  rubber  gloves 
throughout  the  operation  as  an  added  safeguard  against  infection. 

The  abdomen  is  opened  and  the  fetus,  if  it  lies  free  among  the  intestines,  is 
delivered  and  the  cord  tied.  If  it  is  still  enclosed  in  an  unruptured  sac  this  is 
opened  at  the  thinnest  point  and  it  is  removed,  and  any  bleeding  vessels  in  the 
sac  wall  clamped. 

The  sac  is  then  inspected  to  determine  whether  or  not  its  complete  removal 
is  possible.  Extensive  intestinal  adhesions  to  the  sac  wall  may  be  dealt  with 
either  by  peeling  them  off  or  tying  them,  or  by  leaving  considerable  portions  of 
the  sac  on  the  intestines,  and  controlling  the  hemorrhage  from  the  cut  edges  by 
the  cautery  or  by  many  fine  ligatures.  Bleeding  should  always  be  controlled,  as 
far  as  possible,  by  ligating  the  uterine  and  ovarian  vessels  of  the  affected  side. 

When,  however,  the  placenta  lies  spread  out  over  the  intestines  or  the  large 
pelvic  vessels,  it  mil  be  better  simply  to  tie  the  cord  and  drop  it,  and  "to  pack 
the  placental  area  with  gauze  and  await  its  slow  expulsion  piecemeal. 

TThenever  it  is  possible,  when  drainage  is  used,  the  sack  wall  should  be 
stitched  to  the  lower  part  of  the  incision,  so  as  to  exclude  the  peritoneal  cavity 
from  the  drained  area  within  the  sac  (marsupialization). 

The  accompanying  table  of  operations  for  ectopic  viable  fetuses  has  been 
prepared  by  my  friend  Dr.  R.  P.  Harris,  of  Philadelphia.  (See  pages  458  and 
459.) 

The  cases  have  been  separated  into  two  groups,  in  order  not  to  confuse  the 
statistics  by  mixing  the  earlier  ones,  without  any  or  with  only  imperfect  asepsis, 
with  the  later  ones,  in  which  the  aseptic  precautious  were  much  better  observed. 

When  the  extra- uterine  fetus  has  been  dead  for  sev- 
eral weeks  and  the  placental  bruit  has  disappeared,  the  gravity  of  the  opera- 
tion, in  the  absence  of  other  complications,  is  greatly  lessened,  and  it  becomes 
analogous  to  the  removal  of  an  adherent  ovarian  or  dermoid  cyst.  A  complete 
extirpation  of  the  sac  in  this  way  has  been  possible  in  each  of  the  three  cases  of 
exti-a-uterine  pregnancy  operated  upon  in  my  clinic  where  the  fetus  had  died 
during  the  seventh  and  in  two  cases  where  it  had  died  during  the  ninth  month 
of  the  pregnancy.  In  all  five  cases  there  were  no  unusual  difficulties  in  the  way 
of  the  enucleation. 

Under  these  circumstances  the  abdomen  is  opened,  the  adhesions  separated, 
and  the  sac  and  its  contents  removed.  The  chief  risks  come  from  the  large 
incision  which  it  is  necessary  to  make,  associated  with  the  prolonged  exposure 
and  the  handling  of  the  intestines  ;  these  dangers  must  be  guarded  against  by 
keeping  the  patient  warm  with  hot-water  bottles  and  well  covered  with  blankets 
under  the  slieets,  and  by  protecting  the  intestines  from  undue  exposure  by  large 
pieces  of  gauze  wrung  out  of  hot  water. 


458 


EXTRA-UTERINE    PREGN"ANCY. 


PROGRESSIVE 


Ectopic  Viable  Fetuses  delivered 
Operations  and  Results  in  80  Years. 
Recoveries,  9  in  37. 


No. 

Date. 

Operator. 

Localit}-. 

Result  to 
Woman. 

Result 

to 
Child. 

Period  of 
Gestation. 

Time  of  Survival  of 
Child. 

1. 

Nov.,  1809. 

Miiller. 

ITalbeau,  Ger- 
many. 

Recovered. 

Lived. 

9  months. 

('0 

2. 

Aug.  29, 1813. 

Briikert. 

Berlin. 

Died. 

»<• 

9        " 

Well  at  4  years. 

3. 

Dec.    7,  1814. 

Novara. 

Porto   Maurizio. 

" 

" 

9 

(?) 

4. 

1827. 

Mattfeld. 

Tubingen. 

" 

" 

9th  month. 

(0 

5. 

Mar.    1,1841. 

Ilaufif. 

Kirchheim. 

(( 

Alive. 

35  weeks. 

50  hours. 

6. 

1852. 

Lazzati. 

Milan. 

« 

" 

9  months. 

Did  not  breathe. 

7. 

Mar.  27, 1863. 

Koeberle. 

Strassburg. 

" 

u 

9       " 

24  hours. 

8. 

Apr.  21,  1864. 

Greenhalgh. 

London. 

" 

" 

9       " 

1  hour. 

9. 

Mar.   3,  1870. 

Sale. 

Aberdeen,    Mis- 
sissippi. 

'* 

Lived. 

9       " 

0  months. 

10. 

Oct.    5,  1872. 

Scott. 

London. 

" 

Alive. 

30  weeks. 

To  second  day. 

11. 

Aug.  14, 1875. 

Jessop. 

Leeds. 

Recovered. 

Lived. 

33  or  34 
weeks. 

11  months. 

12. 

Mar.   5,  1877. 

Spiegelberg. 

Breslau. 

Died. 

" 

40     " 

3       " 

13. 

May  27,    " 

Smith. 

London. 

" 

Alive. 

9  months. 

30  to  40  minutes. 

14. 

Nov.   5,    " 

Gervis. 

London. 

" 

" 

36+  weeks. 

6  hours. 

15. 

Aug.  19, 1878. 

Fraenkel. 

Breslau. 

a 

" 

33i      " 

24      " 

16. 

May  29,  1879. 

Schroeder. 

Berlin. 

(1 

Lived. 

34 

Well  at  6  months. 

17. 

Dee.  19,     " 

Vedeler. 

Christiania,Nor- 

u 

Alive. 

35         " 

To  second  day. 

18. 

Jan.  10,  1880. 

Litzmann. 

wav. 
Kiel. 

u 

.. 

39i      " 

15  minutes. 

19.  |Feb.    1,     " 

Tait. 

Birmingham. 

" 

Lived. 

9  months. 

Living  at  15  years. 

20. 

May  11,     " 

"Wilson. 

Baltimore. 

" 

" 

9       •' 

18  months. 

21. 

July  26,     " 

Netzel. 

Stockholm. 

" 

Alive. 

9       " 

48  hours. 

22. 

"      9,  1881. 

Martin. 

Berlin. 

Recovered. 

" 

7       " 

Did  not  breathe. 

23. 

"    13,     " 

Beisone. 

Buriasco,   India. 

Died. 

Lived. 

9       " 

Living  in  1895. 

24. 

Feb.  15,  1882. 

Hildebrandt. 

Konigsberg. 

" 

" 

9        " 

25.  [Oct.    3.      " 

" 

" 

" 

Alive. 

34i  weeks. 

Did  not  breathe. 

26.  jJune  6, 1885. 

Williams. 

London. 

Recovered. 

" 

35th  week. 

A  few  minutes. 

27. 

Nov.  4,     " 

Lazare  witch. 

Kharkof,      Rus- 

a 

Lived. 

9  months. 

26  days. 

28. 

Jan.  29,  1886. 

Stadfeldt. 

sia. 
Copenhagen. 

Died. 

u 

9       " 

7  months. 

29. 

Oct.  19,     " 

Chamf)neys. 

London. 

" 

Alive. 

7th  month. 

A  few  minutes. 

30. 

Mar.  30, 1887. 

Jos.  Price. 

Camden,  N.  J. 

" 

" 

7+  months. 

4  hours. 

31. 

Mav  29,     " 

Trcub. 

Leyden. 

Recovered. 

Lived. 

8i      " 

Well  at  7i  years. 

32. 

June  26,     " 

F.  Spaeth. 

Haraburg. 

Died. 

Alive. 

8 

24  hours. 

33. 

Oct.   29,     " 

Breisky. 

Vienna. 

Recovered. 

Lived.  8         " 

19  days. 

34.  I  Mar.  22, 1888. 

Lebec. 

Paris. 

Died. 

Alive.  ,8 

24  hours. 

35.  July  10,     " 

Eastman. 

Indianapolis. 

Recovered. 

Lived.  8 

8  months  13  days. 

36.  Oct.  12,     " 

Egon  Braun. 

Vienna. 

Died. 

"      8*      " 

37.  Nov.   1,     " 

Olshausen. 

Berlin. 

Recovered. 

"      8*      " 

Well  at  one  year. 

Of  the  first  20  there  were  2,  and  of  the  first  30,  there  were  5  maternal  recoveries.  Of  the  37 
there  were  saved  less  than  26  per  cent.  Case  22  set  the  example  of  saving  life  by  exsecting  the 
pregnancy  as  a  tumor.  Under  improved  methods  there  has  been  a  gradual  diminution  of  mor- 
tality for  seventeen  years;  this  has  made  tiie  operation  less  dreaded  and  more  frequently  per- 
formed, as  is  shown  in  the  second  half  of  the  tabular  record. 


TREATMEXT    OF   ADVANCED    EXTEA-UTERIXE    PREGXANCT. 


459 


IMPROVEMENT. 


under  Celiotomy,  1809-1896. 

Operatioxs  AST)  Eesults  IX  10  Years. 
Recoveries,  27  in  40  =  67^  Per  Cent. 


No. 

Date. 

Operator. 

Locality. 

Result  to 
Woman. 

Result 

to 
ChUd. 

Period  of 
Gestation. 

Time  of  Survival  of 
Child. 

38. 

Feb.  11,  1889. 

Carl  Braun. 

Vienna. 

Recovered. 

Alive. 

9   months. 

12  hours. 

39. 

"    27,      " 

Olshausen. 

Berlin. 

" 

" 

8f      " 

1+  hour. 

40. 

Sept.  22,    " 

Negri. 

Venice. 

" 

a 

8 

18  hours. 

41. 

Oct.      9,    " 

Pearce 
Gould. 

London. 

Died. 

ii. 

12      " 

Signs  of  life. 

42. 

Feb.    4,1890. 

Geo.  Rein. 

Kieff. 

Recovered. 

Lived. 

37  weeks. 

Living  in  1894. 

43. 

Apr.  25,     " 

Galabin. 

London. 

Died. 

'* 

7  to  8 
months. 

6  weeks. 

44. 

June  16,     " 

Chrobak. 

Vienna. 

Recovered. 

Alive. 

71      " 

24  hours. 

45. 

"    24,     " 

Taylor. 

Birmingham. 

" 

Lived. 

9'       " 

5  months. 

46. 

Aug.  16,     " 

Negri. 

Venice. 

Died. 

AUve. 

8 

2  days. 

47. 

"     21,     " 

Schoonen. 

Antwerp. 

Recovered. 

" 

8 

A  few  minutes. 

48. 

Feb.    2,  1891. 

Schneider. 

Berlin. 

" 

7 

3  hours. 

49. 

"     12,     " 

Gueniot. 

Paris. 

Died. 

" 

7i      « 

J  hour. 

50. 

June   6,     " 

Frommel. 

Erlangen. 

Recovered. 

Lived. 

9 

4  months. 

51. 

"    16,     " 

Stevenson. 

Cape  Colony. 

" 

Alive. 

8i      " 

48  hours. 

52. 

Nov.  19,     " 

Von  Strauch. 

Moscow. 

•' 

" 

9        " 

Breathed  and  died. 

53. 

Apr.  27,  1892. 

Handfield- 
Jones. 

London. 

Died. 

Lived. 

250th  day. 

Alive  at  3  months. 

54. 

«    29,     " 

Sippel. 

Frankfort      On- 
the-Main. 

" 

" 

7  months. 

5  days. 

55. 

Oct.  23,     " 

M.  Price. 

Philadelphia. 

Recovered. 

" 

10      " 

Well  in  1897. 

56. 

Dec.  29,     " 

Marchand. 

Paris. 

Died. 

(( 

36  weeks. 

8  months. 

57. 

Apr.  15, 1893. 

Sneguireff. 

Moscow. 

" 

« 

8    months. 

18       " 

58. 

May  12,     " 

Urbain. 

La  Bouverie. 

Recovered. 

(( 

9 

59. 

Aug.  25,     *' 

McNutt, 

Oakland.  Cal. 

Died. 

Alive. 

9        " 

A  few  minutes. 

60. 

"     29,     " 

E.  Regnier. 

Vienna. 

Recovered. 

" 

9        " 

Did  not  breathe. 

61. 

Sept.  11,    " 

Roucaglia. 

!Modena. 

" 

Lived. 

7+      " 

23  days. 

62. 

Oct.  15,     " 

Treub. 

Leyden. 

" 

Alive. 

8i      « 

50  hours. 

63. 

Dec.    2,     " 

Hofmeier. 

Wnrzburg. 

" 

" 

9        " 

Did  not  breathe. 

64. 

"     14,     " 

Gueniot. 

Paris. 

Died. 

Lived. 

9 

16  days. 

65. 

Jan.  13,  1894. 

Culling- 
worth. 

London. 

'■ 

i( 

8 

7i  months. 

66. 

April  4,     " 

Werder. 

Pittsburg. 

Recovered. 

t( 

8i      " 

4  days. 

67. 

Sept.   4,     " 

Potherat. 

Paris. 

tt 

" 

(?) 

J^) 

68. 

"    14,     " 

Tournay. 

Brussels. 

<( 

Alive. 

9 

2  hours. 

69. 

Nov.  21,    " 

Eakins. 

Queensland. 

Died. 

Lived. 

Si      " 

(?) 

70. 

Dec.  10,     " 

Geo.  Rein. 

Kieff. 

Recovered. 

'* 

30  weeks. 

Alive  at  a  month. 

71. 

Feb.    3,  1895. 

Pestalozza. 

Florence. 

" 

" 

9    months. 

in  March, 
1895. 

72. 

May    2,    " 

Pinard. 

Paris. 

(( 

» 

7 

"  in  July.  1895. 

73. 

Sept.  29,    " 

Tauffcr. 

Budapest. 

•' 

" 

9 

"  at  58  days. 

74. 

(?) 

Bond. 

Leicester. 

" 

" 

7k      " 

Living  at  5  months. 

75. 

Feb.  26,  1896. 

Ilardie. 

Brisbane.     Aus- 
tralia. 

" 

'* 

8 

Alive  6  hours. 

76. 

»            »              41 

Chrobak. 

Vienna. 

11 

t< 

9 

Living  at  4  weeks. 

77. 

Nov.    7,     " 

Ayers. 

New  York. 

Died. 

'* 

7 

Living  3  weeks. 

Of  the  last  20  there  were  15  recoveries.  Of  the  5  that  died,  only  one  can  be  attributed  prop- 
erly to  the  celiotomy.  Case  59  was  delirious  when  operated  on  and  died  delirious;  case  64  died 
of  peritonitis;  case  65  had  the  plaeonta  closed  in  and  died  in  twenty-six  days;  case  69  removed 
her  dressings,  became  fly-blown,  and  died  on  the  sixteenth  day;  case  77  was  quickly  operated  on, 
lost  very  little  blood,  but  died  the  next  day. 


460 


EXTRA-UTERINE   PREGNANCY. 


Drainage  ought  not  to  be  used  unless  the  case  is  septic  at  the  time  of 
operation.  I  lost  one  of  my  early  cases  where  I  removed  a  seven  months'  fetus 
which  had  lain  dead  and  perfectly  aseptic  for  four  months  in  the  abdomen  of  a 
colored  woman,  by  a  streptococcus  infection  which  undoubtedly  entered  the 


Fig.  531. — Litiiopedion  lying  undisturbed  in  the  Aisdo.minal  Cavity. 

The  stronsr  adliesionK  lioliliiig  it  in  plaeu  and  its  position  are  well  shown.  The  patient  was  a  colored 
woman  forty-five  years  old  vvho^had  had  her  last  child  when  thirty-eight;  four  years  before  entering  the 
clinic  she  became  pregnant,  with  all  the  usual  signs,  and  was  taken  with  perfectly  normal  labor  pains  at  the 
e.vpected  time.  J)r.  liarnum,  who  saw  her  two  months  later,  recognized  an  abdominal  pregnancy.  The  mind 
oftlie  patient  was  unbalanced,  and  she  would  not  allow  any  interference  until  after  four  years  had  passed. 
Operation  by  Dr.  Clark.     Recovery.     U.  II.,  Aug.  14,  1896. 

abdomen  by  the  drainage-tube  openings.  It  is  far  safer  to  trust  the  large  adher- 
ent area  and  numerous  l)its  of  tied-off  tissues  with  their  ligatures  to  the  closed 
cavity  than  to  run  the  slightest  risk  of  infection  from  without  where  there  is  so 
much  dead  space. 


Fig.  532. — Lithopedion  removed  from  the  Abdominal  Cavity  Four  Years  after  a  False  Labor. 


The  placental  attachment  is  in  the  right  uterine  tube.  The  fetus  has  been  freed  from  the  enveloping 
adhesions  and  lifted  out  of  the  abdomen.  Note  the  posture  and  the  peculiar  membrane  coverinsj  all  the 
features  and  inequalities  of  the  body.  There  is  a  deposit  of  calcareous  salts  in  the  envelope  and  in  the  skin ; 
the  rest  of  the  skin  is  leathery  and  converted  into  adipocere. 


TKEATMENT   OF   ADVAXCED    EXTRA-UTERIXE    PREGNAXCY.  461 

Atypical  case  illustrating  the  difficulties  of  an  extra-uterine  pregnancy 
with  a  dead  fetus  advanced  beyond  term  is  that  of  A.  L.  (No.  191),  operated  on 
May  6,  1890. 

The  patient  was  a  negress  twenty-eight  years  old,  pregnant  for  the  first  time. 
Three  years  before  her  pregnancy  she  had  had  a  severe  pelvic  peritonitis.  It 
was  impossible  to  fix  the  exact  date  of  her  pregnancy,  which  must  have  been 
about  four  months  advanced  at  the  end  of  May,  1889,  when  her  menses  came 
on  profusely  and  lasted  forty-five  days,  until  July  10th ;  the  flow  appeared  again 
in  August,  October,  and  December,  1889,  and  in  February,  1890. 

Since  June,  1889,  she  had  been  more  or  less  ill,  spending  much  time  in  bed 
feeling  weak  and  prostrated,  and  suffering  from  a  "  misery  "  in  the  abdomen  and 
back.  An  enlargement  of  the  abdomen  was  noted  in  July,  1889,  and  it  con- 
tinued to  increase  in  size  up  to  October,  when  it  began  steadily  to  decrease. 
She  had  nothing  like  a  false  labor. 

Examination  showed  a  large  resisting  mass,  moderately  tender  on  pressure, 
extending  from  the  left  hypochondrium  to  the  pelvic  floor,  surrounded  above 
and  at  the  sides  by  a  tympanitic  area.  The  uterus,  of  normal  size,  lay  in  front 
of  it,  right  latero-flexed,  and  the  cervix  was  extremely  soft.  I  could 
move  the  mass  above  3  or  4  centimeters  to  the  right  and  to  the  left.  The  1  i  n  e  a 
nigra  was  well  developed,  from  1  to  15  millimeters  broad  below  the  umbili- 
cus ;  linea  albicantes  were  well  marked  on  the  left  side  below  the  umbilicus. 

The  breasts  were  flaccid  and  showed  numerous  lines  concentric  with  the 
nipple  area,  which  was  deeply  pigmented  ;  a  little  milk  was  easily  squeezed 
from  them. 

By  palj)ation  of  the  abdominal  mass  the  angular  prominences  of  the  body  of 
a  child  could  be  felt,  but  the  head  could  not  be  detected  :  the  end  Ivingr  in  the 
pelvis  gave  the  same  uncertain  sensation  one  so  often  recognizes  when  the 
breech  presents  and  never  noted  in  a  head  presentation.  ISTo  fetal  heart  sounds 
or  placental  bruit  could  be  heard. 

At  the  Operation. — An  incision  was  made  12  centimeters  long,  and 
afterward  extended  3  centimeters  above  the  umbiHcus,  exposing  a  mottled  gray- 
ish and  reddish  sac  intimately  united  by  adhesions  to  all  the  surrounding  struc- 
tures. The  adhesions  to  the  abdominal  walls  were  separated  without  much  hem- 
orrhage by  running  the  fingers  in  between  the  sac  and  the  parietal  peritoneum 
with  a  shearing  movement.  The  omentum  was  then  found  so  intimately  adher- 
ent over  the  anterior  surface  of  the  sac  that  it  had  to  be  tied  off  in  its  entire 
breadth  close  to  the  colon.  After  freeing  the  omentum  in  this  way  the  upper 
pole  of  the  cyst  was  exposed,  grasped,  and  drawn  doM-n  into  the  incision ;  it  was 
now  evident  for  the  first  time  during  the  operation  that  the  tumor  was  a  fully 
developed  dead  fetus  lying  with  its  back  to  the  abdominal  wall  and  its  face 
buried  in  adhesions  up  in  the  left  hypochondrium. 

The  adhesions  which  bound  the  child  on  all  sides  to  the  intestines  and  poste- 
rior abdominal  wall  were  no  longer  vascular,  and  were  severed  freely  after  lift- 
ing up  the  child  and  so  making  them  long  enuugh  to  cut  without  injury  to  the 

attached  structure. 

72 


462  EXTRA-UTERINE    PREGNANCY. 

A  broad  mass  of  adhesions,  extending  from  the  shoulder  of  the  child  over 
onto  the  posterior  abdominal  wall,  looked  much  like  a  shawl  thrown  over  it ;  this 
was  tied  oif  and  the  child  entirely  freed  above. 

The  placenta  was  then  found  rolled  up  in  a  large  bail-like  mass  under  its 
ventral  surface,  with  adhesions  in  all  directions  which  were 
easily  separated.  The  point  of  origin  of  the  sac  at  the  right  cornu  uteri 
was  now  clearly  demonstrable,  and  the  right  tube  with  its  ovary  was  removed 
with  the  entire  mass.  About  50  cubic  centimeters  of  blood  was  lost  throughout. 
The  abdomen  was  closed,  according  to  the  technique  at  that  time,  with  drainage, 
and  the  patient  recovered. 

The  vaginal  route  has  been  repeatedly  used  with  success  for  the  re- 
moval of  a  dead  fetus  in  which  the  fetal  head  could  be  distinctly  felt  in  the 
recto-uterine  pouch.  It  is  indicated  in  all  cases  in  which  suppuration  has  already 
set  in,  and  the  fetus  or  any  part  of  the  sac  can  be  felt  through  the  vaginal  vault. 
But  this  mode  of  treatment  should  not  be  followed  when  the  fetus  is  not  felt 
distinctly  in  the  pelvis  and  when  the  placenta  is  recognized  there  by  its  spongy 
feel. 

Important  objections  to  the  vaginal  plan  of  treatment  are  the  difficulty  of 
removing  a  large  fetus  without  extensively  tearing  the  soft  parts  at  the  vaginal 
vault  cases,  and  the  impossibility  of  doing  more  than  simply  removing  the 
fetus  ;  the  sac  and  the  placenta  can  only  be  extracted  under  the  most  favorable 
circumstances.  Under  ordinary  circumstances  a  drain  must  be  inserted  and 
the  secundines  must  be  left  to  come  away  later  with  the  suppuration  of  the  sac. 

The  general  plan  of  the  vaginal  operation  can  not  be  better  described  than 
by  following  the  account  of  a  case  treated  in  this  way  by  Christian  Fenger 
(Ame/'.  Jour,  of  Ohst.,  vol.  xxiv,  1891,  p.  418). 

The  patient,  twenty-eight  years  of  age,  became  pregnant  after  a  single  coitus 
in  March,  1 880 ;  a  month  later  she  experienced  dragging  pains  in  the  right  iliac 
region.  Menstruation  continued  regularly  until  June,  after  which  it  ceased 
until  Xov.  25tli.  In  June  she  noticed  an  enlargement  of  the  right  side  of  the 
abdomen,  which  increased  in  size  without  pain. 

In  November  she  had  a  bloody  discharge  which  continued  until  March, 
1887,  a  year  after  the  conception. 

She  was  examined  the  last  of  Januarj",  1887,  when  the  outlines  of  a  fetus 
could  be  plainly  felt  through  the  abdominal  walls ;  the  head  lay  in  the  left 
iliac  fossa,  and  the  body  was  inclined  upward  to  the  right.  No  fetal  heart 
sounds  could  be  detected,  but  the  placental  bruit  was  quite  plainly  heard  at  a 
point  3  inches  below  the  umbilicus  and  a  little  to  the  left. 

The  patient  had  never  been  conscious  of  any  fetal  movements,  and  had  no 
idea  she  was  pregnant.  She  had  an  attack  of  chicken-pox  about  the  end  of 
February,  1887 ;  on  March  2d  the  vaginal  discharge  ceased,  and  on  March  6th 
the  placental  souffle  was  inaudible. 

Dr.  Fenger  operated  March  13,  1887,  removing  a  fully  developed  fetus 
through  the  vagina,  with  the  patient  in  the  lithotomy  position.  A  median  in- 
cision was  made  down  through  the  perineum  to  enlarge  the  held  of  operation, 


COMPLICATIONS.  463 

and  with  the  index  finger  resting  on  the  tumor  in  the  rectum  a  transverse  in- 
cision was  made  posterior  to  the  cervix  witli  a  cautery  knife.  Upon  opening 
the  sac  a  moderate  amount  of  ahnost  clear  fluid  escaped,  and  the  head  of  the 
fetus  presented  in  the  opening.  As  it  was  too  large  to  be  delivered  intact, 
craniotomy  was  performed,  and  portions  of  the  cranial  bones  were  removed  with 
bone  scissors.  The  head  with  the  rest  of  the  body  was  then  delivered  with 
comparative  ease. 

A  digital  examination  showed  that  the  placenta  was  attached  high  up  in  the 
left  iliac  fossa  and  adherent  on  all  sides.  The  sac  was  then  irrigated  and  two 
large  rubber  drainage-tubes  inserted. 

In  three  days  the  discharge  had  become  fetid.  Irrigation  was  frequently 
used.  On  the  eleventh  day  a  small  piece  of  placenta  came  away,  and  on  the 
seventeenth  day  an  examination  showing  that  the  margins  of  the  jjlacenta  were 
free ;  it  was  broken  up  and  completely  removed  with  the  fingers.  On  the  fol- 
lowing day  all  odor  had  disappeared,  and  in  a  week  more  the  patient  was 
allowed  to  get  out  of  bed.  In  six  weeks  after  operation  menstruation  re- 
appeared ;  the  patient  was  discharged  from  the  hospital  in  four  months  with  a 
uterus  normal  in  size  but  adherent  to  the  left  side  of  the  pelvis. 

Treatment  of  an  Interstitial  Pregnancy. — If  an  interstitial  pregnancy  is  dis- 
covered before  rupture,  a  gentle  effort  should  be  made  to  ojDen  the  sac  wall  into 
the  uterine  cavity  by  dilating  the  cervix  and  using  a  sound. 

If  the  abdomen  has  been  opened  the  same  maneuver  may  be  carried  out 
more  effectively  and  with  less  danger  by  grasping  the  sac  with  the  abdominal 
hand,  and  so  directing  the  movements  of  the  sound  introduced  into  the  uterus. 

If  the  sac  has  already  ruptured  and  the  patient's  condition  is  fairly  good,  the 
effort  may  be  made  to  save  the  structures  by  clearing  the  sac  out  and  suturing 
the  rupture. 

Any  active  hemorrhage  should  be  controlled,  either  by  immediate  ligation 
of  the  ovarian  and  uterine  arteries  of  that  side,  or  in  a  more  serious  case  by  first 
controlling  the  circulation  by  throwing  a  rubber  ligature  around  the  body  of  the 
uterus  Ijelow  the  sac  until  the  vessels  going  to  it  are  tied. 

Complications. — The  ectopic  gestation  may  be  complicated  in  a  variety  of 
ways  other  than  by  the  natural  frequently  recurring  difiiculties,  such  as  hemor- 
rhage, adhesions,  and  suppuration. 

One  of  the  commonest  complications  met  with  is  a  peculiar  tendency  to 
mental  aberration,  first  noted  by  Dr.  Joseph  Price. 

Another  complication  which  I  have  noted  and  find  mentioned  by  various  sur- 
geons is  a  liability  to  nephritis;  one  of  my  cases,  which  had  gone  three 
months  over  term  and  was  operated  upon  on  an  emergency  by  Dr.  H.  Robb, 
died  within  twenty -four  hours  with  an  advanced  nephritis  and  fatty 
degeneration  of  the  liver. 

Another  of  my  cases  operated  upon  by  Dr.  II.  Robb  was  complicated  hy  an 
appendicitis.  The  patient  was  a  negress,  admitted  to  the  hospital  with  a 
small  rapid  pulse,  an  elevated  temperature,  marked  dyspnea,  and  constant 
vomiting.     The  abdomen  was  symmetrically  distended,  prominent  in  the  mid- 


464  EXTRA-UTERINE    PREGNANCY. 

die,  indistinctly  fluctuating,  and  tender  on  pressure.  Her  mental  condition  was 
peculiarly  dull.  Pier  last  menstruation  was  seven  weeks  before,  but  no  more 
exact  history  could  be  obtained.  The  uterus  was  somewhat  enlarged,  and  there 
was  clearly  fluid  in  the  pelvis,  but  no  mass  could  be  felt.  The  breasts  con- 
tained some  milk.  By  means  of  a  hypodermic  syringe  some 
dark  bloody  fluid  was  drawn  off  in  the  median  line  of  the 
abdomen,  and  a  diagnosis  of  extra- uterine  pregnancy  was 
made;  the  fluid  contained  a  pure  culture  of  colon  bacilli,  and  for 
this  reason  a  perforation  of  the  intestine  was  suspected. 

At  the  operation  a  stream  of  blood  spouted  7  inches  high  out  of  the  ab- 
dominal incision,  and  the  right  tube  was  found  ruptured  in  the  isthmus. 

The  patient  died  the  following  day,  and  at  the  autopsy  a  perforation 
of  the  vermiform  a p  j) e n d  i x  was  found  with  a  circumscribed  abscess 
and  general  peritonitis. 

In  several  instances  the  extra-uterine  pregnancy  has  been  found  complicated 
by  an  ovarian  tumor  of  the  opposite  side. 

A.  Martin  has  seen  one  case  in  which  there  was  torsion  of  the  pedicle  of  an 
extra-uterine  sac. 

Pregnancy  in  a  Rudimentary  Horn  of  the  Uterus. — Closely  allied  to  the  extra- 
uterine gestations  are  those  cases  in  which  the  pregnancy  occurs  in  a  rudimen- 
tary horn  of  the  uterus.  This  malformation  is  due  to  the  failure  of  Miiller's 
ducts  to  coalesce  in  their  upper  portion  in  early  fetal  life,  and  the  uterus  in  such 
a  case  bifurcates  at  some  point  above  the  vagina.  One  side  may  develop  into  a 
large  gibbous  uterine  body  with  a  normal  tube  and  ovary,  while  the  other  re- 
mains rudimentary ;  the  undeveloped  side  is  either  connected  with  the  cervix  by 
a  fine  canal,  or  completely  shut  off,  but  remains  in  open  communication  with  its 
own  tube  and  ovary,  which  are  normally  developed. 

The  muscular  band  which  unites  the  rudimentary  half  of  the  uterus  with 
the  cervix  is  about  1  centimeter  in  breadth  and  from  3  to  Y  centimeters  long. 

When  a  canal  exists,  however  fine,  communicating  with  the  vagina,  the  preg- 
nancy may  occur  at  any  time  in  the  rudimentary  horn. 

If,  however,  the  band  of  connection  between  tlie  rudimentary  horn  and  the 
uterus  is  atresic,  then  the  pregnancy  can  only  occur  by  the  mi- 
gration of  an  impregnated  ovum  from  the  normal  side,  or 
by  a  similar  migration  of  the  spermatozoa. 

Pregnancy  occurs  in  a  rudimentary  horn  of  the  uterus  most  frequently  be- 
tween the  ages  of  twenty  and  thirty,  and  often  in  women  who  have  previously 
borne  children  from  the  better  developed  side. 

The  tendency  of  this  form  of  pregnancy  is  to  rupture  at  a  somewhat  more 
advanced  stage  than  in  tubal  pregnancy — that  is,  from  the  fourth  to  the  fifth 
month.  The  rupture  is  most  apt  to  occur  at  the  thinnest  point  near  the  origin  of 
the  tube,  and  the  amount  of  blood  extravasated  is  large ;  in  these  respects  the 
pregnancy  resembles  the  tubo-ovarian  form.  In  some  instances,  however,  the 
pregnancy  has  advanced  to  full  term ;  it  may  be  characterized  by  intermittent 
pains  throughout.     At  or  near  term  pains  set  in,  and  for  several  days  the  patient 


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DESCRIPTION  OF   PLATE  XXIV. 

PREGNANCY   IN  A  RUDIMENTARY  LEFT  UTERINE   HORN;    MAGNIFIED  SECTIONS  OP 

FIG.   633. 

Fig.  1  is  a  section  through  Miiller's  duct  at  point  c.  The  epithelial  lining  has 
dropped  off ;  the  underlying  stroma  cells  are  swollen,  have  proliferated,  project  into 
and  partially  obliterate  the  lumen.  The  individual  cells  resemble  decidual  cells.  Ex- 
ternal to  the  stroma  are  cross-sections  of  muscle  fiber. 

Fig.  2  is  a  section  through  the  right  tube  at  a,  Fig.  533.  It  represents  a  segment 
of  the  tube  at  this  point.  The  tubal  folds  are  normal,  and  have  an  intact  epithelial 
covering.  The  cavity  of  the  tube  contains  many  cells ;  the  majority  of  these  have 
small,  round,  deeply  staining  nuclei.  Scattered  throughout  this  mass  of  c^ls  are 
some  giant  cells. 

Fig.  3  represents  two  of  the  giant  cells  seen  in  Fig.  2  highly  magnified ;  surround- 
ing these  are  some  of  the  cells  that  are  seen  as  small  dots  in  Fig.  2.  One  giant  cell 
is  irregularly  circular,  and  has  scattered  throughout  its  protoplasm  numerous  vesicular 
nuclei;  some  are  oval,  others  are  triangular.  The  second  giant  cell  is  oblong.  Its 
nuclei  are  similar  to  those  of  the  one  described.  The  giant  cells  are  cross-sections  of 
the  so-called  placental  giant  cells;  surrounding  them  are  typical  decidual  cells  and 
small  round  cells. 


PLATE  XXIV 


Fig.V 


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PREGXAXCY    IX   A    RUDIMEXTARY    HORX   OF   THE    UTERUS.  465 

passes  tlirougli  a  false  labor,  productive  at  the  utmost  of  a  bloody  vaginal 
discharge. 

The  developed  half  of  the  uterus  is  enlarged  and  con- 
tains a  well-formed  decidua  which  sooner  or  later  is  cast  off. 

In  one  instance  in  which  the  pregnancy  terminated  after  several  months 
without  rupture,  at  an  autopsy  many  years  later  an  abscess  was  found  in  the 
rudimentary  horn  containing  fetal  bones. 

In  another  case  the  fetal  bones  were  found,  covered  with  lime  salts,  on  the 
pelvic  floor,  and  there  was  a  well-defined  scar  in  the  rudimentary  uterus. 

An  accurate  diagnosis  is  always  difficult  to  make.  If  the  case  is  seen  after 
rupture  there  will  usually  be  no  time  to  go  into  greater  detail  than  to  determine 
the  existence  of  an  intrapelvic  hemorrhage  due  to  an  abnormal  pregnancy. 

If  the  case  is  seen  before  rupture,  at  an  early  date,  two  signs  will  be  of  value 
in  determining  the  character  of  the  pregnancy  :  the  first  is  the  fact  that  the  de- 
veloped side  deviates  at  an  angle  of  from  forty  to  sixty  degrees  from  the  normal 
position ;  the  second  is  the  fact  that  the  pregnant  horn  is  found  by  a  rectal 
examination  to  be  connected  with  the  uterus  by  a  broad  band 
which  is  attached  at  the  lower  part  of  the  uterine  body. 

The  treatment  is  that  of  an  extra-uterine  pregnancy.  If 
rupture  has  occurred,  the  abdomen  should  be  opened  and  the  rudimentary  uterus 
removed  with  the  ovum. 

If  rupture  has  not  occurred,  and  the  pregnancy  is  still  in  the  first  six  months, 
it  is  best  to  extirpate  it  in  the  same  way.  After  the  sixth  month,  in  view  of  the 
lessened  dangers  of  rupture,  the  ojieration  may  be  postponed,  keeping  the  pa- 
tient under  close  observation  all  the  while,  until  the  child  is  viable,  when  the 
abdomen  should  be  oj^ened,  the  child  delivered,  and  the  undeveloped  uterus  and 
tube  removed  completely ;  the  ovary  should  not  be  removed. 

The  operation  itself  does  not  oifer  any  special  difficulties,  as  the  tumor  has 
a  well-defined  pedicle,  and  all  the  vessels  supplying  it  are  within  easy  reach. 
After  opening  the  abdomen  and  protecting  the  intestines,  the  sac  is  lifted  out 
and  the  ovarian  vessels  of  that  side  tied  near  the  pelvic  brim ;  the  round  liga- 
ment is  next  tied,  and  the  top  of  the  broad  ligament  opened  and  its  fold  sepa- 
rated until  the  uterine  artery  is  exposed  below  the  sac ;  this  is  then  ligated  and 
the  sac  removed. 

The  layers  of  the  broad  ligament  are  now  approximated  with  a  continuous 
catgut  suture,  and  the  abdomen  closed  without  a  drain. 

An  interesting  case  of  this  kind  occurred  in  my  practice  in  the  summer  of 
1894,  when  I  was  called  in  consultation  as  to  the  advasability  of  an  operation 
upon  a  woman  presenting  all  the  symptoms  of  a  rnj^tured  extra-uterine  preg- 
nancy. I  was  al)sent  at  the  time,  and  she  died  of  internal  hemorrhage  ;  the 
specimens  and  notes  have  been  furnished  by  Dr.  (4.  "\V.  "Wilkins,  of  Balti- 
more. 

She  was  a  German,  twenty-nine  years  old,  married,  and  had  had  one  child 
several  years  before.  She  subsequently  had  had  two  attacks  of  severe  pain  on 
the  left  side,  called  "  ovaritis." 


466  EXTRA-UTERINE    PREGNANCY. 

The  menses  were  always  regular  until  Aug.  28,  1894,  when,  after  three 
months  of  amenorrhea,  she  began  having  uterine  coutractions  accom- 
panied by  agonizing  pelvic  pains,  with  rectal  and  vesical 
tenesmus  and  marked  abdominal  tenderness. 

There  was  no  vaginal  discharge ;  a  tumor  the  size  of  an  orange  could  be 
felt  to  the  left  of  and  behind  the  uterus.  The  pains  continued  two  days,  when 
they  suddenly  ceased,  and  she  experienced  a  period  of  calm,  fol- 
lowed by  fainting,  extreme  pallor,  and  cold  sweats,  with  a 
small,  feeble  pulse,  and  evident  distention  of  the  abdomen. 

A  sound  was  then  introduced  into  the  uterus,  which  was  found  to  be  10 
centimeters  in  length  and  empty.  The  patient  died  six  hours  after  the  onset  of 
the  fainting  spell. 

At  the  autopsy  the  abdomen  was  found  to  contain  4,000  cubic  centimeters 
of  blood,  and  a  three  to  four  months'  fetus  with  its  investing  membrane,  con- 
nected by  its  cord  with  a  rudimentary  left  uterine  horn,  was  floating  in  the  peri- 
toneal cavity.     The  left  tube  and  ovary  were  slightly  adherent  (see  Fig.  533). 

The  specimen  was  examined  by  Dr.  T.  S.  Cullen,  whose  pathological  report 
I  use  in  abstract. 

At  the  autopsy  a  well -developed  right-horned  uterus  was  found,  to  which  a 
pregnant  rudimentary  left  horn  was  attached  ])y  a  muscular  band.  This  preg- 
nant left  horn  had  raptured.  The  corpus  luteum  was  on  the  right 
side  opposite  to  the  pregnancy. 

Microscopically,  the  well -developed  right  uterus  was  shown  to  possess 
typical  decidua,  and  the  right  tube  contained  remains  of  the 
placenta  lying  free  in  its  lumen;  the  cells  of  the  corjDus  luteum  in 
the  right  ovary  closely  resembled  normal  decidual  cells.  The  pedicle  joining 
the  two  horns  at  the  cervix  contained  a  canal  blind  at  both  ends  and  5  millime- 
ters in  diameter,  lined  with  a  single  layer  of  cylindrical  epithelium  resting  on  a 
delicate  stroma  ;  external  to  this  was  a  circular  muscular  coat,  and  covered  again 
by  longitudinal  muscular  fibers  (see  Plate  XXIV). 

The  only  possible  explanation  of  the  location  of  the 
pregnancy  was  by  a  migration  of  the  ovum  and  spermatozoa 
out  through  the  right  side  and  over  into  the  left  hy  way  of 
the  abdominal  cavity. 

An  almost  identical  case  is  described  by  C.  Ruge  {Zeitschr.  f.  Geh.  und 
Gyn.^  Bd.  ii,  1878,  p.  27),  in  which  the  rudimentary  right  horn  was  ruptured 
and  the  corpus  luteum  was  found  in  the  left  ovary. 


Fig.  534. — Hek.nma  of  the  Pregnant  Uterus  in  the  Negress. 

The  uterus  has  escaped  through  a  ventral  hernia,  due  to  a  celiotomy,  May  3, 1894,  of  which  the  sear  is 
7»lainly  seen.  The  patient  went  to  term  and  was  delivered  of  a  living  child  by  a  normal  labor.  A.  R., 
■CJyn.  No.  1390,  Dec.  5,  1895. 


CHAPTEE    XXXV. 

THE    RADICAL    CURE    OF    HERNIA. 

1.  Definition  and  varieties. 

2.  Etiology  and  mechanism. 

3.  Pathology. 

4.  Treatment :    1.  In  general.      2.  Special  forms,      a.  Hernia  in  the  linea  alba.      h.  Umbili- 

cal hernia,     c.  Inguinal  hernia,     d.  Ovarian  hernia  and   hernia  of   the  uterine  tube. 
e.  Femoral  hernia. 

Introductory. — An  abdominal  hernia  is  fonned  by  a  protrusion  of  some  part 
of  the  abdominal  viscera  tlirough  a  natural  or  an  acquired  opening  in  some 
portion  of  the  abdominal  walls. 

A  great  variety  of  heruise  may  arise  in  this  way,  many  of  them  of  rare  oc- 
currence ;  strictly  speaking,  we  should  also  include  under  this  title  the  various 
pelvic  herniee,  such  as  prolapsus  uteri,  obturator  hernia,  etc.  It  is  my  intention, 
however,  to  dwell  only  upon  the  treatment  of  the  commoner  forms  which  occur 
in  the  anterior  abdominal  parietes,  through  the  oblique,  transverse,  and  recti 
muscles  and  their  fasciae,  as  well  as  under  Poupart's  ligament ;  that  is  to  say, 
umbilical,  ventral,  inguinal,  and  femoral  h  e  r  n  i  ob  . 

Causes  of  Hernia . — The  essential  factor  in  the  production  of  these 
herniae  is  a  deficiency  in  the  fibrous  aponeurosis  which  gives  strength  to  the  ab- 
dominal walls ;  if  this  deficiency  is  a  congenital  one,  the  hernia  may  be  noted 
soon  after  birth ;  if,  on  the  other  hand,  the  wall  is  merely  weak,  the  rupture  may 
then  develop  as  soon  as  stress  is  put  upon  it  by  posture  and  by  an}'^  form  of 
exercise  which  tends  to  increase  the  intra-abdominal  pressure ;  it  is  for  this 
reason  that  liernia  is  more  frequently  found  in  the  laboring  classes. 

The  umbilical  ring  and  the  inguinal  canal  s  are  by  nature  the 
weakest  points  in  the  abdominal  walls;  but  the  umbilicus  is  well  protected 
against  this  danger  by  its  position  high  up  in  the  abdominal  wall,  where  it  is 
least  liable  to  feel  the  force  of  pressure. 

In  the  linea  alba  nature  has  provided  against  the  possibility  of  hernia 
under  all  ordinary  conditions  by  the  strong  interlacement  of  the  bundles  of 
fibrous  tissue  from  the  conjoined  tendons  of  the  muscles  of  both  sides.  This 
advantageous  arranorement  is  sacrificed  Avhenever  a  median  incision  is  made  into 
the  abdominal  cavity,  never  to  be  restored  by  any  approximation,  however  j^er- 
fect,  followed  by  union,  however  good ;  and  when  the  apposition  of  these  tissues 
after  an  operation  is  inaccurate,  or  the  line  of  union  is  weakened  by  suppuration, 
hernia  is  especially  liable  to  occur. 

The  so-called  ventral  hernia  noted  after  repeated  pregnancies  is  in 
reality  nothing  more  than  a  diastasis  of  the  recti  muscles  with  a  thinning  out  of 

467 


468  THE    RADICAL   CURE    OF   HERNIA. 

this  fibrous  layer ;  it  is  therefore  not  a  true  hernia,  but  a  pouching  out  of  a  large 
portion  of  the  abdominal  wall  in  consequence  of  overstretching. 

The  formation  of  a  hernia  commonly  depends  upon  the  following 
factors : 

1.  The  existence  of  a  weak  point  in  the  abdominal  wall  through  which  some 
portion  of  the  viscera  may  be  forced  out  to  form  a  sac. 

2.  The  near  presence  of  a  viscus — generally  either  omentum  or  intestines,  or 
])oth — which  may  act  as  a  wedge  to  drive  the  weak  point  ahead  of  it  and  enter 
the  hernial  sac  to  form  its  contents. 

3.  The  application  of  an  intra-abdominal  pressure  from  within  outward  by 
means  of  the  muscular  abdominal  walls  acting  upon  the  contained  viscera ;  in 
this  way  the  viscus  lying  nearest  the  weak  point  is  forced  against  it,  and  if  its 
form  pern)its,  it  enters  it  as  a  plug. 

4.  The  continued  or  the  repeated  actions  of  the  intra-abdominal  pressure 
cause  the  weak  spot  to  yield  further,  and  so  push  the  viscera  out  into  a  pocket 
under  the  skin.  The  neck  of  the  hernial  sac  is  formed  by  the  sur- 
rounding layer  of  fibrous  tissue,  and  the  sac  itself  is  that  part  of  the  peri- 
toneum and  subperitoneal  tissue  which  lies  between  the  neck  and  the  skin. 

It  is  evident  that  under  ordinary  circumstances  hernia  is  most  liable  to  occur 
in  those  parts  which  are  most  dependent,  and  upon  which  the  omentum  and 
small  intestines  continually  lie  while  the  abdominal  muscles  are  in  active  ex- 
ercise. 

It  is  safe  to  say  that  inguinal  and  femoral  hernia,  due  to  muscular  effort,  de- 
pend upon  the  erect  position  for  their  production,  while  if  the  ancestral  position 
on  all  fours  were  still  the  natural  one,  umbilical  hernia  would  be  the  commonest 
form. 

Another  cause  of  hernia  is  an  increase  in  the  contents  of  the  abdominal 
cavity,  stretching  and  subjecting  all  parts  of  the  abdominal  wall  to  a  pressure 
from  within  outward.  Umbilical  hernia  commonly  owes  its  origin  to  such  a 
change  in  the  relation  between  container  and  contents,  and  is  oftenest  observed 
in  fat  women.  An  umbilical  hernia  is  also  often  seen  where  it  otherwise  would 
never  have  occurred,  when  the  intra-abdominal  pressure  is  greatly  increased  by 
the  presence  of  an  ascites ;  it  is  indeed  one  of  the  characteristic  marks  of  an 
ascitic  accumulation.  In  these  cases  it  is,  as  a  rule,  only  an  interesting  clinical 
sign  and  free  from  any  danger;  the  umbilicus  stands  out  dark  in  color,  forming 
a  little  cushiony  eminence,  and  upon  pressing  on  it  the  fluid  is  felt  shooting 
through  the  narrow  opening  into  the  abdomen,  and  the  finger  can  often  be 
pushed  into  the  ring ;  as  soon  as  the  pressure  is  withdrawn  the  cushion  forms 
again. 

This  sign  is  seen  with  a  smaller  amount  of  ascitic  fluid  than  otherwise  would 
be  the  case  when  the  abdomen  is  occupied  by  a  tumor  of  considerable  size,  and 
inasmuch  as  ascitic  accumulations  are  quite  constantly  observed  with  papillary 
ovarian  tumors,  the  umbilical  eminence  is  suggestive  and  a  sign  of  some  value. 
Once  in  a  while  little  papillary  masses  find  their  way  into  the  sac  and  grow 
there,  and  so  give  a  clew  to  the  diagnosis. 


INTRODUCTORY. 


469 


In  one  ease  of  this  kind  mj  patient,  some  days  after  tapping  for  a  large 
ascitic  accumulation,  had  a  strangulated  intestinal  hernia  upon  which  I  operated, 
cutting  the  ring  larger  and  releasing  the  bowel.  She  recovered,  and  died  about 
a  year  later  of  the  advance  of  the  papillary  disease. 

Light  is  thrown  upon  the  mechanism  of  the  formation  of  a 
hernial  sac  by  a  study  of  the  multiple  omental  herniae  found  projecting 
through  the  holes  of  the  glass  drainage-tube,  at  one  time  so  much  used  in 
al)dominal  surgery.  Here,  as  I  have  often  had  occasion  to  observe,  a  minute 
portion  of  the  omentum  slips  into  one  of  the  holes  whose  lumen  becomes 
choked ;  this  produces  a  stasis  in  the  -circulation,  and,  while  arterial  blood  is 
still  pumped  in.  the  venous  blood  can  not  escape  and  the  hernial  mass  swells 
and  becomes  edematous  and  so  keeps  pulling  upon  its  neck  and  dragging  in 
more  and  more  of  the  omentum,  until  the  tube  is  entirely  choked  or  the  mass 
finally  becomes  gangrenous. 

In  a  hernia  in  the  abdominal  wall  the  mechanism  is  somewhat  similar ;  a  bit 
of  omentum  or  part  of  the  wall  of  the  bowel  slips  through  the  weak  spot  in 
the  fibrous  tissue  ;  beyond  this  point  there 
is  no  pressure  or  constriction ;  the  con- 
sequence is  that  with  the  impeded  circu- 
lation the  beginning  hernial  mass  swells, 
forniing  a  marked  neck,  where  it  trav- 
erses the  fibrous  tissue,  and  so  exercises 
traction  and  makes  it  easy  for  more  and 
more  of  the  viscera  to  push  out  into  the 
sac. 

If  the  constriction  is  tight,  gangrene 
may  take  place  ;  on  the  other  hand,  it 
may  be  just  sufticient  to  imj^ede  the  cir- 
culation ;  or  if  the  neck  stretches,  the 
compression  at  this  point  will  be  l)ut 
slight  and  the  viscera  may  slip  to  and 
fro,  even  returning  spontaneously  when 
the  patient  lies  down. 

The  commonest  content  of  the 
sac  is  the  omentum,  which  often  com- 
pletely fills  it  and,  by  its  adliesions  to  the  neck  and  to  the  sac  walls,  prevents  the 
ingress  of  any  other  organ,  in  this  way  curing  the  hernia  after  a  fashion  by  plug- 
ging it  up.  The  frequency  with  which  the  omentum  is  found  employed  in  this 
wa}^  makes  it  evident  that  this  is  undoubtedly  one  of  its  important  uses.  This 
natural  cure  is  made  surer  if  in  addition  to  the  omentum  a  serous  exudate 
forms  within  the  sac,  filling  it  to  the  limit  of  its  capacity. 

Such  a  hernia  when  it  produces  no  symptoms  may  just  as  well  be  let  alone ; 
often,  however,  the  pain  accompanying  this  condition  necessitates  an  operation. 

The  only  other  organs  quite  constantly  found  in  abdominal  hernia?  are 
loops    of    the    small   intestines;  wherever  the  hernia  contains  portions 


Fll.     '>J>, — GtNERAL    PkIN(  II'I  JS  OP   TIIL    RADICAL 
UpH{VTION    I-OU    IItRM\ 

The  skin  and  pillars  and  fascia  divided  and 
the  hernial  sac  protruding.  Tlie  sac  is  then 
either  returned  or  cut  off  at  the  neck. 


470 


THE    RADICAL   CURE    OF   HERNIA. 


of  the  bowel,  operation  should  be  resorted  to  on  account  of  the  constant  risk  of 

strangulation,  gangrene,  and  death. 

An  operation  upon  a  hernia  is  always  indicated  when  the  patient  is 

liable  to  attacks  of  vomiting  and 
has  pain  in  the  region  of  the  her- 
nia, and  finds  it  at  times  difficult 
to  reduce  (replace)  the  contents  of 
the  sac.  I  have  seen  patients  who 
were  subject  to  these  attacks  every 
few  weeks  followed  by  immediate 
relief  after  the  reduction  of  the 
hernia,  which  they  had  learned 
to  do  themselves.  Sooner  or  later 
such  hernige  are  pretty  sure  to 
become  strangulated,  and  the  stran- 
gulation may  lead  to  a  fatal  re- 
sult before  an  operation  can  be 
performed. 

Incarceration  or  j)ersistence  of 
the  contents  in  the  hernial  sac,  dull 
pain  in  the  region  of  the  hernia  in- 
creasing with  exertion,  or  gradual 
enlargement  of  the  sac,  are  signs 
demanding   operation,    unless   such 

contra-indications  as  grave  cardiac  lesion,  advanced  nephritis,  asthma,  or  great 

obesity  exist. 

Obese  patients  often  suffer  from  fatty  heart,  as  a  consequence  of  whicli 

they  are  subject  to  attacks  of  dyspnea  or  asth- 
ma.    In  the  event  of  an  operation  they  take 

the  anesthetic  badly ;  the  anesthesia  is  apt  to 

be  prolonged,  and  their  convalescence  is  often 

marked  by  an  exaggeration  of  the  dyspnea  and 

by  irregularity  of  the  heart's  action  ;  they  also 

show  a  diminished  resistance  to  infection,  and 

60  may  die  quickly  from  peritonitis. 

For  these  reasons  I  advise  against  operation 

in  excessively  fat  women  if  it  is  possible  to 

make  them  comfortable  by  supporting  ban- 
dages or  trusses.      Too  often,  however,  the 

indications  for  operation  are  so  urgent  that  it 

must  be  done.     The  unusual  dancrers  of  the 

operation  should  always  be  fully  explained  to 

the  relatives  or  the  patient,  in  order  to  reheve      ^''0-  537.-Gi.rNERAL  Principles  of  the 

i               '  Radical  Operation  for  Hernia. 

the  surgeon  from  an  undue  weight  of  respon-             Silver-whe  mattress  sutures  drawn  up, 

Kihilitw  twisted,  and  the  ends  turned  down,  com- 

biuiuiy.  pletely  closing  the  hernial  orifice. 


Fio.  536. — General  Principles  of  the  Radical  Oper- 
ation for  Hernia. 
The  sac  returned  and  the  kanj,'aroo  tendon  or  silk- 
worm gut  or  silver-wire  mattress  sutures  laid  through 
the  fa.seia,  including  also  the  muscle,  when  possible,  on 
both  sides. 


HERXIA    IX   THE    LIXEA    ALBA. 


471 


Out  of  355  eases  of  hernia  operated  upon  in  Dr.  "W.  S.  Halsted's  clinic  there 
were — 


Male. 

Female. 

Inguinal 

Umbilical  and  ventral 

Femoral 

309 
21 
25 

274 

6 

11 

35 
15 
14 

Total    

355 

291 

64 

Fig.  538.— General  Principles 
OF  THE  Radical  Operation 
roR  Hernia. 

The  mattress  suture  tied. 
Note  the  puckering  of  the  fibi'ous 
lamella  and  the  inclusion  of  the 
muscle. 


Treatment  in  General . — The  broad  lines  of  the  treatment  of  all 
forms  of  hernise  through  the  iibrous  aponeurosis  of  the  abdominal  wall  are 

similar — viz. :  (1)  to  cut  through  the  skin  and  open 
the  sac ;  (2)  to  reduce  the  hernia,  if  necessary  cutting 
the  ring ;  (3)  to  dissect  out  and  expose  the  iibrous 
ring  or  the  canal ;  (-i)  to  remove  the  sac  and  close  the 
peritoneum ;  (5)  to  close  the  fibrous  ring  or  the  canal 
with  buried  sutures,  always  embracing  the  muscular 
tissue  if  possible ;  and  (6)  to  close  in  the  fat  and  the 
skin. 

The  points  absolutely  essential  in  the  treatment  are 
to  catch  and  bring  together  the  fibrous  and  adjacent  muscular  tissues  stout 
enough  to  withstand  any  pressure  which  may  be  put  upon  them  subsequently 
from  within,  and  to  approximate  the  tissues  with  a  suture  material  which  is 
non-irritating  and  at  the  same  time  is  strong  enough  to  bind  them  together 
until  firm  union  has  taken  place. 

A  careful  dissection  well  back  into  the  tissue  surrounding  the  ring  yields 
satisfactory  material  for  the  new  wall,  and  the  use  of  buried  silver  wire  or  silk- 
worm -  gut    sutures    answers   the 
second. 

"With  this  general  statement 
as  to  the  principles,  it  remains  to 
apply  them  to  the  particular  forms 
of  hernia,  witli  such  comments  as 
the  special  conditions  call  for. 

Hernia  in  the  Linea  Alba. — 
Hernia  in  the  linea  alba, 
when  it  occurs,  is  a  direct  sequence 
of  an  abdominal  section,  and  owes 

its  origin  to  the  division  of  the  fibrous  interlacement  of  the  strong  fascia  over- 
lying the  recti  muscles,  followed  by  imperfect  union  after  the  operation. 

Such  a  hernia  can  generally  be  prevented  by  proper 
suturing  after  operation,  as  described  in  Chapter  XX,  p.  40. 

It  is  oftenest  found  in  those  cases  where  for  motives  of  expediency  a  drain 
has  been  inserted  in  the  lower  part  of  the  wound,  keeping  a  portion  of  the  walls 
apart,  or  where  the  convalescence  has  been  complicated  by  suppuration  in  tlie 


Fio.  539.— General  Principles  of  the   Radical  Opera- 
tion FOR  Hernia. 
Interrupted  catgut  sutures  passed,  but  not  yet  tied,  in 
tlie  intervals  between  the  mattress  sutures  of  silkworm  gut 
or  silver  wire. 


472 


THE    RADICAL    CURE    OF    HERNIA. 


abdominal  wall.  This  gap  fills  in  with  a  plug  of  fibrous  tissue  and  constitutes 
a  weak  point  ready  to  yield  when  pressure  is  brought  to  bear  upon  it. 

The  size  of  such  a  ventral  hernia  varies  from  one  not  larger  tlian  the  end  of 
a  finorer  to  a  mass  includino-  most  of  the  intestines.  A  hernia  small  at  the  start 
may  grow  to  an  immense  size ;  marked  discomforts  are  often  entailed,  but  the 
risk  to  life  is  not  great.  I  have,  however,  seen  one  case  where  the  patient  died 
of  strangulation  twenty-seven  years  after  ovariotomy  (see  Chapter  XXXVII). 

Before  operating,  the  patient  should  be  examined  lying  on  her  back  with 
knees  drawn  up.  The  hernia  is  grasped  on  the  two  sides  and  its  contents 
manipulated  until  they  are  all  returned  to  the  abdominal  cavity.  Omental  and 
intestinal  adhesions  to  the  sac  wall  may  prevent  a  complete  reduction  ;  sometimes 
this  can  not  be  done  before  opening  the  sac. 


V 

\-\i,.  .'iln. — I  )i'ki:ai  lox   Fur  a   \"knti;ai.   IIeknia. 
The  incision  in  the  median  line  has  exposed  the  thick  fascia  coverin<r  the  rectus:  this  is  grasped  between 
the  tliuinb  and  foretintrer,  proteetinu  the  peritoneum  and  guiding  the  scissors,  which  are  then  used  to  split 
the  fascia  all  around  the  hernial  ring,  exposing  the  muscle. 

After  returning  the  contents  the  hole  in  the  wall  is  easily  felt,  and  when  it 
is  large  the  whole  hand  may  be  slipped  into  the  abdomen  and  the  most  per- 
fect palpation  of  the  abdominal  and  pelvic  viscera  made  with  only  the  thin 
skin  and  the  peritoneum  intervening,  like  a  glove.  The  edges  of  the  round 
or  oval  ring  feel  distinct  and  sharp,  but  it  is  important  to  note  that  the 
area  of  fibrous  tissue  which  must  be  dissected  out  in  operating  is  much  greater 
than  the  manifest  thin  margin  of  the  ring  outlined  in  this  way.  The  radical 
operation  for  this  form  of  hernia  is  therefore  always  more  extensive  than  one 
would  naturally  expect  it  to  be. 

Operation. — The  operation  is  begun  by  making  an  oval  incision,  cutting 
out  the  old  scar  with  all  of  the  relaxed  wrinkled  skin  covering  the  hernial  sac. 
The  incision  is  made  most  cautiously  through  the  skin  and  the  thinned-out  sub- 


HERNIA    IX   THE    LINEA    ALBA. 


473 


Peritonei)  >>i 


Fig.  541. — Tissues  grasped  by  the  Mattress  Su- 
tures  IN    CLOSING    THE    IIeKNIA. 

More    muscle    sliould    "be    embraced    than    is 
shown  in  the  lig'ure. 


cutaneous  tissues  on  all  sides,  and  the  peritoneum  is  picked  up  between  two 
forceps  and  opened  with  extreme  care.  A  rapid  bold  method  of  inci.sing  will 
risk  cutting  an  adherent  coil  of  intestine  often  found  surprisingly  close  to  the 
surface. 

Two  fingers  are  now  introduced  within  the  peritoneum,  and  under  their 
guidance  the  peritoneum  is  cut  through  on  all  sides  to  correspond  mth  the  in- 
cision in  the  skin ;  in  this  way  an  oval 
piece  is  removed  and  the  abdomen  is 
opened.  Intestinal  and  omen- 
tal adhesions  are  commonly  found 
and  must  be  looked  for  as  soon  as  the 
peritoneum  is  opened.  Omental  ad- 
hesions can  usually  be  freed  by  pulling 
upon  them.  Intestinal  adhesions  must 
be  dealt  with  more  carefully.  These 
are  generally  attached  to  the  wall  by 
a  loose  welj  of  tissue,  and  can  be  dis- 
sected loose  by  drawing  upon  them  a 

little  and  cutting  the  adhesions  with  scissors.  Wlien  all  these  adhesions  are 
freed  it  is  important  to  look  for  more  ^vithin  the  abdomen  adjacent  to  the  ring, 
and  to  separate  them  in  like  manner,  until  all  the  coils  of  intestines  are  freed 
from  any  aljnormal  attachments. 

A  gauze  napkin  is  now  laid  ujjon  the  intestines  within  the  abdomen  to  keep 
them  out  of  the  way  while  the  fibrous  ring  is  being  dissected  out. 

The  edges  of  a  fibrous  ring  will  be  found  occupying  the  whole 
adjacent  area  between  the  skin  and  the  peritoneum,  and,  in  places  where  it  is 
not  clearly  seen,  overlying  fatty  and  loose  fibrous  tissue  should  be  dissected  off, 
laymg  it  bare.     The  fii)rous  ring  thus  bared  is  not  the  tissue  which  must  be 

brought  together  to  close  the  hernia,  but 
is  merely  a  mass  of  dense  connective 
tissue  which  covers  in  the  recti  muscles 
and  the  true  abdominal  fascia  overlying 
them. 

The  next  step  is  to  dissect  off  this 
tissue  and  to  e x p o se  the  recti 
muscles  below  and  the  fascia 
above  the  m ,  This  may  be  done 
either  by  catching  up  a  bit  of  the  tissue 
with  f<)rce])s  and  cutting  it  off  in  strips 
with  scissors,  or  by  lifting  up  the  nuis- 
cle,  which  can  be  easily  palpated,  and  splitting  the  overlying  scar  tissue  with 
scissors,  as  shown  in  Fig.  540.  The  underlying  muscle  is  often  f(»und  ])ale  and 
atrophic.  In  the  upper  and  lower  angles  (►f  the  opening  the  dissection  nuist  be 
carried  deeper  than  at  the  sides  in  order  to  reach  layers  of  fibrous  tissue  strong 
■enough  to  hold  firndy  together  when  united  by  suture. 
73 


Fio.  .542. — Mattress  Sutures  uniting  the  Recti 
Muscles  and  their  Overlying  Fasci.e. 

Tlie  sutures,  as  a  rule,  embrace  more  tissue  than 
is  shown  in  the  tijiure. 


474 


THE    RADICAL   CURE    OF   HERNIA, 


After  such  a  preparation  the  wound  presents  an  entirely  different  appearance 
from  that  when  lirst  exposed,  for  now  the  natural  layers  of  the  abdominal  wall, 


Fio.  543.— Incarcerated  Umbilical  Hernia  in  a  Fat  Woman,  removed  at  Autopsy. 
The  patient  had  anemia  and  fatty  detreneration  of  the  viscera,  aflfectinsr  chiefly  the  heart,  liver,  and  kid- 
neys. The  hernia  was  hi-loV)ed,  the  size  of  a  child's  head,  and  the  skin  over  it  was  tense  and  red.  Ihe  sac- 
contained  otnentutn  and  a  part  of  the  transverse  colon  twenty  centimeters  long.  Old  fibrous  bands  I'assed 
from  the  ringr  at  the  neck  of  the  sac  to  the  contents  at  their  entrance.  Age,  fifty-three.  Autopsy  «8l. 
%  natural  size. 


the  peritoneum,  the  muscles,  the  fascia,  and  the  skin  are  all  clearly  brought  to- 
view  by  the  clean  dissection. 


HEKXIA    IX   THE    LIXEA    ALBA. 


475 


The  hernia  is  now  closed  bj  a  separate  suture  of  each  of 
its  layers.  The  peritoneal  layer  is  brought  together  first  from  top  to  bottom 
by  a  continuous  suture  of  catgut. 

The  fibrous  layer,  together  with  the  recti  muscles,  most  important  of 
all,  is  now  united  by  a  series  of  silver-wire  or  silkworm-gut  mattress  sutures. 

The  strong  fibrous  tissue  on  either  side,  somewhat  retracted  beneath  the  skin 
and  fat,  is  first  caught  with  several  pairs  of  artery  forceps  and  drawn  out.  The 
stout  silver- wire  mattress  sutures  are  now  drawn  through  the  fascia  and 
the  underlying  muscle  by  a  carrier,  so  that  one  embraces  about  1  centi- 
meter of  the  tissue,  and  is  situated  about  2  centimeters  distant  from  the  last 
suture.  The  suture  enters  and  emerges  at  about  8  or  10  millimeters  from  the 
edge  of  the  cut. 

After  the  sutures  are  all  in  place  they  are  taken  up  in  turn,  each  end  in  a 
pair  of  forceps,  and  tied  or  twisted  and  cut  off,  and  the  ends  of  the  silver  wire 


ryi\t^  >--' 


iHSG 


Fig.  544. — The  IIeuxial  Sac  uemoved. 

Showinff  the  contents,  the  omentum  loaded  with  fat,  the  transverse  colon,  and  appendices  epiploieos. 
%  natural  size  (see  Fig.  543). 

turned  down  to  one  side.  Oatgut  sutures  are  then  placed  between  the  ]ier- 
manent  ones,  leaving  no  looj)hoIe  for  the  escape  of  the  intestines,  \^y  this 
means  a  firm  closure  is  effected  strong  enough  to  act  as  an  effectual  barrier 
against  any  tendency  of  the  intra-abdominal  pressure  to  force  the  intestines  out 
again. 

Small  bleeding  vessels  in  the  upper  part  of  the  wound  are  now  tied  with 
fine  catgut  ])efore  closing  tlie  skin.  If  tiiere  is  a  thick  layer  of  subcutaneous 
fat  it  should  be  approximated  with  a  continuous  catgut  suture. 


476 


THE    RADICAL    CUKE    OF    HERXIA. 


Tlie  skill  is  now  united  with  a  subcuticular  catgut  suture,  and  the  abdominal 
dressing  applied. 

It  will  be  safe  after  such  a  union  of  the  fibrous  tissue  to  allow  the  patient 
to  rise  from  her  bed  in  fourteen  days,  but  any  strain  on  the  recti  should  be 
avoided  if  possible  for  several  months. 

"Umbilical  Hernia. —  An  umbilical  hernia  is  one  which  takes  place  at  the  um- 
bilical riiig ;  it  owes  its  origin  to  a  natural  weakness  in  the  abdominal  wall  at 
the  site  of  the  cicatrix  left  by  the  umbilical  cord.  There  is  always  a  natural 
separation  of  the  recti  muscles  at  this  point  and  a  close  approximation  of  the 
peritoneum  and  the  skin,  surrounded  by  a  dense  ring  or  cylinder  of  tibrous 
tissue. 


Fig.  545. — Anatomy  of  the  Inguinal  Canal. 

The  skin  and  fat  turne-d  hack,  e.\po.sin<r  the  ai)oiR'un)sis  of  the  e.xtornal  oblique  mut<ele.  Showinar  also 
its  triaii!.'ular  division  over  the  intruinal  canal,  the  opcninfr  below  for  the  exit  of  the  round  lijranient  (external 
rin>.'i,  tiie  relation.s  to  I'oui.art'.s  liirarneut,  and  the  intereoluinnar  fibers  binding  together  the  inner  and  outer 
pillars. 

Owing  t(t  the  location  of  this  naturally  weak  point,  under  ordinary  conditions 
the  abdominal  viscera  are  not  brought  to  bear  directly  upon  it  during  the  action 
of  the  intra-abdominal  pressure.  In  addition  to  this,  the  free  border  of  the 
omentum  and  the  small  intestines  occupy  the  lower  part  of  the  abdomen,  leav- 
ing the  flat  upper  part  of  the  omentum  with  the  colon  and  the  stomach  in  appo- 
sition to  the  uml)ilicus:  these  structures  from  their  very  form  are  less  liable 
to  enter  the  opening. 

When,  however,  by  the  increase  of  fat  in  the  abdomen  the  mutual  relations 
of  the  viscera  are  disturbed  and  the  relations  between  the  abdominal  walls  and 


UMBILICAL    HERNIA. 


4:77 


Fio.  54(5.— Anatomy  or  the  iNdUiNAi.  C.\nai.  in  its  Dkkim-.u  Lavkh.^. 

Kxposin.'  tlic  intereoluinnar  fibers  and  the  iiponeumsis  of  the  external  ol)liqiuMmisele  .livuKMl  mul  tumo.l 
hack,  showing' the  internal  rinir  above  an<l  ti.e  obli-iue  dhvetion  ot  the  inj^mnal  eanal,  wliieh  'f  ^"1"';"  ; 
dilate.l  by  the  neek  of  a  hernial  sac,  shown  cut  off.  The  upper  bor-ler  of  the  eanal  is  t..niied  hy  the  "">"•' 
obli.iue  a'n.l  trai.sversalis  muscles,  which  curve  around  the  inner  side  ot  th.'  sac  to  make  the  ^•'^".l""ini  u  n- 
.ion  fonninL'  the  lower  wall  of  the  canal.  The  roun.l  liiramcnt  is  seen  ai,'ainst  the  outer  sac  wall,  an.l  tlu, 
genit<i-crural  and  ilio-inguinal  nerves  lie  to  the  outside  of  this  ajrain. 


478 


THE    RADICAL    CURE    OF    HERNIA. 


r" 


A 


Fig.  547.— Fiust  Step  ix  the  Operation  fok  Inguinal  Hernia. 

Showing  the  sac,  after  division  of  the  skin  and  subcutaneous  fat,  separating,'  the  pillars  of  the  aponeurosis 
of  the  external  oblique  muscle.  The  dotted  line  indicates  the  ne.xt  step,  the  incision  exposing  the  sac.  The 
round  ligament  is  seen  in  the  lower  angle  of  the  wound ;  it  lies  above  this  posterior  to  and  at  the  outer  side 
of  the  sac. 


UMBILICAL   HERXIA. 


4Y9 


their  contents  are  altered,  creating  the  need  for  more  room,  the  needed  space  is 
often  found  by  forcing  the  viscera  out  under  the  skin  at  the  navel,  the  weakest 
point  in  the  wall,  and   so  establishing   a   supplementary   ab- 

dominal c  a  v-  i  t  y ,  a  s   i  t   w  e  r  e  .     This  sac  or  cavity  may  be- 

come    so     large  ,         that  all  the  small  intestines,  and  the  cecum  with 

its  vermiform  ap-         N^         pendix,  colon,  and  sigmoid,  are  accommodated  in  it. 


Fig.  54:8. — Second  8tep. 

Showiiiffthe  sac.  tocretlier  with  the  round  ligament,  exposed  and  drawn  out  of  the  wound;  a  provisional 
lifCaturc  above,  not  includinir  the  round  liifament,  fixes  the  site  of  the  amputation  of  tlie  sac.  The  dotted 
line  indicates  the  position  of  the  next  incision  tsee  Fig.  549.) 

Umbilical  hernia  occasionally  occurs  as  the  result  of  prolonged  labor  accom- 
panied by  powerful  contractions  of  the  abdominal  walls,  when  the  stress  of  the 
pressure  may  be  felt  in  the  upper  part  of  the  abdominal  cavity  which  now  con- 
tains the  omentum. 

Operation. — An  operation  for  an  umbilical  hernia  must  do  one  of  two 
things,  both  designed  to  obviate  the  risk  of  an  intestinal  strangulation  at  the 
neck  of  the  sac. 


480 


THE    RADICAL    CURE    OF    HERNIA. 


of  tlie  sac  are  voluminous,  aud  the 
in  size  to  the  remaining:  viscera. 


1.  To  effect  a  radical  cure  by  uniting  the  fibrous  walls 
by  suture  in  all  cases  in  which  the  contents  of  the  hernial  sac  can  be  put 
back  without  dangerously  increasing  the  intra-abdominal  pressure. 

2.  To  make  the  opening  so  large  that  no  longer  will  there 
be  any  danger  o f  s  t  r  a n  g  u  1  a  t i o  n  in  those  cases  in  which  the  contents 

abdomen  so  contracted  and  adjusted 
that  the  hernia  is  put  back  with  diffi- 
culty, and  retained  in  the 
abdomen  at  the  expense  of 
a  greatly  increased  intra- 
abdominal pressure. 

The  radical  cure 
is  elfected  by  excising  the 
redundant  skin  and  perito- 
neal pouches  which  are 
found  in  large  hernige,  and 
cautiously  opening  the  sac  ; 
the  adherent  omentum  and 
intestines  must  next  be  care- 
fully freed  from  the  walls 
and  drawn  out  of  any  of 
the  subsidiary  sacs  or  loculi 
often  found  ;  they  are  then 
replaced  in  the  abdomen 
and  held  there  by  a  gauze 
pad. 

A  good  -  sized  cufE  of 
peritoneum  is  then  freed, 
dissected  off  from  the  inner 
surface  of  the  ring,  and 
turned  into  the  abdomen, 
and  the  gauze  taken  out 
and  the  peritoneum  closed 
by  a  continuous  catgut  su- 
ture. 
Tlie  fibrous  i-ing  in  a  small  hernia  must  now  be  dissected  away,  exposing 
the  edges  of  the  recti  muscles  ;  any  extnided  peritoneum  lining  the  sac  or  sac- 
culi  must  also  be  removed  with  scissors  and  forceps.  The  opening  is  then  closed 
by  several  mattress  sutures  of  silkworm  gut  laid  close  together,  so  as  to  bring 
the  muscles  and  the  fascia  on  the  right  and  the  left  sides  into  snug  apposition  ; 
after  this  the  sul)cutaneous  fat  is  united,  and  then  the  skin  is  closed  with  a  sub- 
cuticular catgut  suture, 

I  have  found  it  necessary  to  relieve  several  large  nmbilical  hemise  by  open- 
ing the  sac  and  simply  pushing  the  finger  between  the  peritoneum  and  the  lower 
border  of  the  ring  and  cutting  the  ring  down  from  3  to  G  centimeters  in  the  me- 


Fio.  549.— Third  Stkp. 
The  sac  ineised,  as  indicated  in  the  last  figure,  exposing  its  con- 
tents, which  arc  nnluced;  tlie  sac  is  then  loosened  from  its  sur- 
rounding attachments  and  from  the  round  ligament   and  excised 
close  to  the  j^rovisional  ligature. 


IXGUIXAL   HERXIA.  481 

dian  line  in  a  direction  toward  the  symphysis.  I  have  done  this  in  cases  where 
the  intestines  had  to  he  forced  back  into  the  abdomen  and  persistently  re-es- 
caped, and  the  effort  to  hold  them  there  by  closing  the  abdomen  pnt  them  under 
too  great  tension.  After  the  operation  it  is  of  the  utmost 
importance  to  give  firm  support  to  the  lateral  walls  of 
the  abdomen  by  a  snug  bandage  extending  from  the 
lower  ribs  down  over  the  hips  ;  this  prevents  lateral  ten- 
sion upon  tlie  sutures. 

Inguinal   Hernia. — Of   two   hundred    and  forty-four  "^^^^ 

cases  of  inguinal  hernia  operated  upon  by  my  colleague        t'>«-  550.— Fourth  Step. 
Dr.    W.    S.    Halsted,    only   twenty  -  seven    occurred   in     of  the  t^^lu^  IS^rS 

women  tures   before  allowing   it  to 

.     _  _  _  retract  into  the  abdomen. 

The  infrequency  of  inguinal  hernia  in  women  as  com- 
pared with  men  is  due  largely  to  the  difference  in  occupation  of  the  two  sexes. 

Childbearing  is  not  an  etiological  factor  in  the  production  of  inguinal  hernia, 
])ecause  the  strong  impact  of  the  abdominal  walls  in  labor  falls  upon  the  large 
gravid  uterus  which  occupies  the  lower  abdomen  and  keeps  away  the  smaller 
organs,  the  omentum,  and  the  intestines. 

Another  reason  why  inguinal  hernia  is  more  frequent  in  men  than  in  women 
is  the  difference  in  the  contents  of  the  inguinal  canal.  In  man  the  inguinal 
canal  carries  the  spermatic  coi-d,  accompanied  by  its  arteries  and  often  large 
dilated  veins,  while  in  woman  there  is  only  the  small  round  ligament  with  a  few 
tiny  vessels. 

This  form  of  hernia  is  most  likely  to  be  produced  in  women  by  lifting  heavy 
tubs  or  buckets,  washing  clothes  in  a  stooping  posture,  and  sweejiing. 

The  hernia  may  vary  in  size  all  the  Avay  from  a  pouting  at  the  internal  ingui- 
nal ring,  or  an  ovoid  swelling  filling  the  canal,  to  a  large  pendulous  mass  extend- 
ing down  into  the  labium  majns. 

The  symptoms  produced  are  a  sense  of  weakness  or  of  discomfort,  with  pain 
when  the  hernia  is  in  the  canal.  8trangulati(m  does  not  often  occur.  I  had 
one  case,  however,  in  which  a  diverticulum  from  the  side  of  the  bowel  was  caught 
and  strangulated,  and  an  abscess  formed  beside  it  (hernia  Lit  trie  a).  This 
was  incised  by  the  attending  physician,  who  unfortunately  laid  open  the  bowel 
at  the  same  time,  leaving  a  fecal  fistula.  At  the  operation  M'hich  I  was  called 
upon  to  jierform  su1)sequently  it  was  necessary  to  dissect  out  the  whole  sac  and 
cut  off  the  diverticulum  of  the  bowel  at  the  junction  with  the  sound  intestine, 
which  was  then  sutured.  This  was  followed  by  a  complete  recovery.  In  a 
similar  case  in  a  man  with  a  fecal  fistula  in  the  scrotum,  after  dissecting  ont  the 
diseased  tissues  I  closed  the  opening  in  the  lateral  wall  of  the  bowel  by  suturing 
the  right  testicle  over  it  on  all  sides. 

The  general  principles  of  the  operation  are  the  same  as  in  the  operation  foi- 
a  hernia  in  the  linea  alba,  making  the  necessary  changes  to  adapt  the  steps  to  the 
altered  anatomical  conditions. 

There  are  two  ways  of  getting  at  an  iiiguinal  hernia  :  first,  in  those  ciiscs  in 
which  the  hernia  exists  as  a  complication   of  some  other  alulominal  affection 


482 


THE    RADICAL   CURE    OF    HERNIA. 


which  needs  celiotomy,  the  easiest  way  to  reach  it  is,  after  the  abdomen 
has  been  opened,  to  introduce  two  fingers  of  the  left  hand,  and  to  locate  the 
position  of  the  hernia  either  by  the  exit  of  the  round  ligament  through  the 
wall,  or  by  the  weak  spot  readily  felt  above  Poupart's  ligament ;  the  thinned- 
out  inguinal  canal  is  pushed  forward  with  the  fingers  until  it  makes  a  decided 
prominence  on  the  skin  surface.  Taking  the  scalpel  in  the  other  hand,  the 
operator  now  cuts  down  through  the  skin,  subcutaneous  fat,  aponeu- 

rosis of  the  external  obhque  muscle  I  J  into  the  canal,  the  fingers 
within   saving  the   deeper   structures        (jg         from  injury. 


Fig.  551.— Fifth  Step. 

Shows  the  clo.-*urf  of  tlie  insruinal  canal  with  silver-wire  inattres.s  sutures  and  the  disposition  of  the  round 
lifranieiit,  whifli  is  Lrou-rlit  out  between  the  tirst  and  second  sutures  directly  under  the  skin  and  subcuta- 
neous fat.  The  internal  ohlique  and  the  transversalis  muscles  are  seen  along'the  upper  margin  of  the  canal. 
Each  suture  transti.xes  the  aponeurosis  of  tlie  external  oblique  and  the  internal  oblique  and  transversalis 
muscles  above  and  I'oupart's  li<rament  below.  The  loops  of  the  sutures  are  pocketed,  especially  the  lower 
ones,  v.liere  the  tension  is  greater.     The  round  lif;aiiient  is  not  detached  more  tJian  is  necessary. 

Sutures  are  then  introduced  in  the  manner  to  be  described.  If  the  hernia 
sac  is  small  there  is  no  necessity  of  excising  it,  as  the  operation  will  be  quite  as 
effective  without  this  step. 

The  method  elaborated  by  Halsted  {Johns  Hopl'.  IIosp.  BuL,  vol.  i,  Dec, 
1889;  The  Radical  Cure  of  Hernia)  and  Bassini  {Arch.  f.  Min.  Chir.,  Bd.  xl, 
1890 ;    Ueler  die  Behaiid.  der  Leistenhr.)  for  the  radical  cure  of  inguinal  hernia 


INGUINAL    HERNIA. 


483 


insures  the  greatest  number  of  satisfactory  results,  and  I  shall  follow  this  quite 
closely  in  my  description. 

In  the  male  the  spermatic  cord  and  its  artery  must  be  carefully  preserved 
from  injury  during  the  operation,  and  so  placed  in  a  new  canal  as  to  avoid  com- 
pression of  the  cord.  Atrophy  of  the  testicle  only  takes  place  when  the  veins 
are  excised  or  injured. 


Fig.  552. — Sixth  Step. 
The  mattress  sutures  liave  been  drawn  up  and  twisted  and  tlic  subcutaneous  fat  and  skin  are  being  closed 
over  the  round  lijjament  by  a  subcuticular  continuous  suture. 

In  women  the  round  ligament,  which  takes  the  place  of  the  spermatic  cord,  is 
smaller  and  unimportant,  and  may  be  safely  transfixed  by  the  sutures. 

If  the  round  ligament  is  densely  adherent  to  the  sac,  as  is  often  the  case  in 
strangulated  or  in  incarcerated  herniji',  I  do  not  attemj)t  to  isolate  it,  but  prefer 
to  excise  it  with  the  sac. 

Operation. — An  incision  is  made  at  an  angle  of  about  25  degrees  above 
Poupart's  ligament,  and  from  2  to  8  centimeters  distant  from  it,  beginning  at 


484 


THE    RADICAL   CURE    OF    HERXIA. 


the  spine  of  the  piibes  and  extending  upward  and  outward  beyond  the  internal 
abdominal  rino^. 


^. 


Attach  m  en  t  of  flee  tus> 
to     i^^ y//7 .  pu  h  . 


Fig.  553. — Operation  for  the  RATnrAi,  Ctrf.  of  a  Larok  Ivgtinat,  TTerxia  where  the  Coxjoined  Ten- 
don IS  Deficient. 

Tlii.s  deficit  is  substituted  by  the  rcctuis  muscle.  The  inteiTuptcd  silver-wire  sutures  are  seen  in  plaen 
ready  to  approximate  tlic  left  rectus  with  its  sheath  to  Poupart's  liixanient,  in  tlie  manner  shown.  Note  tlu-, 
puckerinjr  to  be  produced  by  the  two  lower  sutures  to  train  more  tissue,  f  C.  round  ligament  cut  off  in  the 
drawing  for  the  sake  of  clearness;  this  emerges  between  the  first  and  second  sutures. 

Tlie  skin,  subcutaneous  fat,  and  intereohimnar  fascia  are  divided  in  order 
(see  Fig.  547),  and  the  aponeurosis  of  the  external  oblique  muscle  is  divided  and 
dissected  down  to  its  junction  with  Poupart's  ligament. 

The  sac  is  found  lying  l)etween  the  lower  l)order  of  the  internal  oblique 
muscle  and   Poupart's  ligament.     If  the  sac  is  free  it  is  separated  from   the 


INGUINAL   HERNIA. 


485 


round  ligament  and  opened  at  its  apex ;  if  tlie  omentum  or  intestines  are  in  the 
sac  tliey  will  usually  drop  back  into  tlie  abdominal  cavity  of  tlieir  own  weight, 
or  they  can  be  gently  returned  with  a  piece  of  gauze. 

The  sac  is  then  laid  freely  open  and  closed  just  outside  the  internal  abdomi- 
nal ring  with  two  or  three  mattress  sutures  of  fine  silk.  The  sac  should  not  be 
ligated  en  masse,  but  in  sections,  in  order  to  prevent  strangulation  of  so  nmch 
peritoneum,  as  well  as  to  avoid  the  shpping  of  the  mass  ligature. 

The  neck  of  the  sac  is  divided  aljout  1  centimeter  distal  to  the  constricted 
point,  and  allowed  to  drop  back  into  the  abdominal  cavity  (see  Fig.  550). 

Mattress  sutures  of  silver  wire  (No.  24)  are  now  introduced  through  the 
aponeurosis  of  the  external  oblique  muscle  and  the  internal  oblique  muscle  ap- 
pearing in  the  wound,  and  transfixing  the  round  ligament,  thence  into  Poupart's 
ligament,  and  back  through  the  same  structures  to  form  the  square.  These 
sutures  are  placed  1  centimeter  apart  down  to  the  spine  of  the  pubes  (see  Fig. 
551). 


Fig.  5o4.— Showing  the  facility  with  which  the  Rectus  Mfsole,  rei-easeh  from  its  Sheath,  can  be 

DRAWN    OVER    ANU    ATTACHED    TO    PoVPAKT's    LiGAMENT,    (^OVEKINO    IN    THE    EnTIUE    InoIINAL    CaNAL. 


After  the  sutures  are  drawn  up,  bringing  the  divided  aponeurosis  into  snug 
apposition,  they  are  twisted  five  times  and  turned  to  one  side  upon  the  aponeu- 
rosis, pointing  slightly  downward. 


4S6  THE    EADICAL   CURE   OF    HERNIA, 

The  aponeurosis  of  the  muscle  is  neatly  closed  with  a  continuous  catgut  su- 
ture, after  which  the  fat  is  brought  into  apposition  and  the  skin  is  closed  with  a 
subcutaneous  catgut  suture. 

In  large  hernige,  in  which  the  conjoined  tendon  is  obliterated  or  so  relaxed 
as  to  be  useless  in  closing  the  opening,  Bloodgood's  method  of  transjilantation 
and  suture  of  the  rectus  to  fill  in  the  deficit,  strengthening  the  wall  by  the  in- 
clusion of  muscular  tissue,  may  be  employed  with  advantage  (see  Johns  Hojph. 
IIosp.  Rep.,  1898).     (See  Figs.  553  and  554.) 

The  rectus  is  secured  by  a  vertical  incision  through  its  sheath  laterally  about 
5  centimeters  long,  beginning  just  above  the  pubes.  The  sutures,  which  unite 
the  transplanted  muscle  to  Poupart's  ligament  as  far  out  as  the  position  of  the 
transplanted  round  ligament,  catch  both  the  muscle  and  its  overlying  sheath  in 
addition  to  the  other  tissues. 

Ovarian  Hernia. — Hernia  of  the  ovary,  of  the  uterine  tube,  and  of  the  ovary 
and  the  tube  together,  and  of  the  uterus,  of  the  bladder,  and,  on  the  right  side, 
of  the  vermiform  appendix,  are  also  observed. 

The  ovarian  hernia  may  occur  alone  or  in  conjunction  with  the  tube,  or  the 
tube  alone  may  be  found  in  the  sac,  and  with  any  of  these  unusual  forms  of 
hernia  the  omentum  and  the  intestines  may  also  be  found.  In  a  large  experi- 
ence I  have  myself  seen  but  two  cases  of  hernia  of  the  ovary,  both  associated 
with  congenital  malformations,  and  out  of  twenty-seven  cases  of  hernia  in 
women,  Ilalsted  had  but  two,  both  of  which  were  brought  on  in  middle  life  by 
a  strain,  and  in  each  the  tube  and  the  ovary  wei-e  found. 

It  is  important  to  recognize  the  existence  of  these  unusual  forms  of  hernia, 
not  only  for  the  sake  of  attaining  as  much  diagnostic  precision  as  possible,  but 
because  of  the  altered  nature  of  the  operation  and  the  special  treatment  re- 
quired. An  adherent  inflamed  vermiform  appendix  may  require  removal ;  if 
the  presence  of  the  bladder  in  the  sac  is  not  recognized  it  may  be  incised  or 
torn,  and  a  vesico-abdominal  fistula  be  the  result ;  it  is  important  to  determine 
with  regard  to  the  ovary  and  the  uterine  tube  whether  they  are  sound  and  to 
be  returned  to  the  abdominal  cavity  or  whether  they  are  diseased  and  to  be  re- 
moved. 

Etiology. — Ovarian  and  tubal  hernia  may  be  either  congenital  or 
acquired;  the  tube  is  always  found  in  the  sac  with  the  ovary  in  congenital 
forms,  but  when  the  tube  is  found  alone  in  the  sac  the  hernia  is  usually  acquired. 

Out  of  38  cases  of  ovarian  hernia  collected  by  Englisch,  27  were  inguinal, 
9  femoral,  and  1  an  obturator  and  ischiatic  hernia.  Out  of  67  cases  of  ovarian 
hernia,  27  were  accompanied  by  enterocele ;  these  observations,  made  by  Lang- 
ton  {St.  Barth.  IIosp.  Hep.,  1882),  were  for  the  most  part  upon  children. 

The  congenital  cases  are,  as  a  rule,  bilateral,  and  are  largely,  as  in 
my  own  cases,  associated  with  malformation  of  the  genitals,  atresia  of  the  vagina, 
absence  of  the  uterus,  and  a  unicorn  or  a  bicornute  uterus ;  the  natural  explana- 
tion of  such  herniffi  seems  to  be  that  the  canal  of  Nuck  is  persistent,  and  then 
tliat  the  round  ligament  acting  as  its  homologue  in  the  male,  the  gubernaculum 
testis,  conducts  the  ovaries  down  the  inguinal  canal.     It  does  this  easily,  as  tha 


OVARIAN    HERNIA.  487 

restrain  of  tlie  attachment  to  a  normally  developed  uterus  is  wanting.  In  the 
acquired  cases  it  is  probable  that  the  long,  movable  tube  enters  a  pre-existing 
sac  first,  and  drags  the  ovary  in  with  it.  A  hernia  of  the  uterus  occurs  usually 
after  the  menopause. 

An  ovary  in  such  a  situation  may  undergo  any  of  the  alterations  to  which 
it  is  liable  in  the  normal  situation.  It  may  become  adherent,  or  converted  into 
masses  of  cysts,  or  hemorrhagic,  or  it  may  form  a  dermoid  or  a  multilocular 
cystoma  or  a  sarcoma. 

Symptoms. — The  tumor  in  the  inguinal  canal  is  usually  painful,  either 
periodically  at  the  menstrual  periods  or  constantly  with  monthly  exacerbations. 
It  is  most  suggestive  when  a  little  girl  who  has  had  an  indolent  swelling  in  the 
groin  reaches  puberty  and  the  lump  suddenly  becomes  painful. 

The  patient  is  sometimes  entirely  incapacitated  for  work,  and  one  of  my  own 
cases  figured  in  the  text  (Fig.  555)  complained  especially  on  going  upstairs.  In 
a  case  of  Deneux  {Recherches  sur  les  heniies  de  Fovaire,  1813)  the  pain  during 
pregnancy  became  unbearable,  and  a  patient  of  Leopold's,  who  had  a  hernia  of 
a  rudimentary  left  uterine  horn  with  the  ovary  and  the  tube,  suffered  so  much 
that  she  attempted  several  times  to  commit  suicide.  A  patient  of  Beigel's, 
with  double  ovarian  femoral  herniae,  experienced  the  most  intense  pain  in  the 
ovary  during  coitus. 

On  account  of  this  sensitiveness  it  is  usually  impossible  to  wear  a  truss. 

The  inguinal  swelling  is  usually  tender  on  pressure,  producing  a  characteris- 
tic sickening  sensation  similar  to  that  experienced  when  a  prolapsed  ovary  is 
pressed  upon  behind  the  cervix. 

At  the  menstrual  period  the  tumor  swells  decidedly,  even  doubling  its  size. 

Pregnancy  may  occur  even  when  both  ovaries  are  in  the  inguinal  canals  i 
pregnancy  may  also  take  place  in  a  uterus  which  lies  in  a  hernial  sac,  as  in  Scan- 
zoni's  case  of  a  woman  who  acquired  a  small  hernia  when  thirty  years  old  by 
lifting  a  heavy  wine  cask.  The  tumor  was  small,  irreducible,  and  swelled  per- 
ceptibly at  the  menstrual  periods.  After  an  attack  of  typhoid  fever  it  became 
as  larsre  as  a  man's  fist ;  on  makiuff  a  vaginal  examination  the  cervix  could  not 
be  felt,  and  the  vagina  was  found  pulled  up  into  a  long,  narrowing  canal.  She 
had  previously  borne  two  children,  and  she  conceived  a  third  time  in  the  hernial 
uterus,  which  swelled  as  large  as  two  fists,  when  she  aborted  and  the  swelling 
was  quickly  reduced.  Within  a  year  she  conceived  again,  and  the  tumor  grew 
as  large  as  a  man's  head  and  covered  the  pubes,  when  pain  set  in  and  there  was 
retention  of  urine.  A  catheter  was  now  passed  into  the  uterus  and  some  warm 
water  injected,  and  a  dead  fetus  and  the  placenta  were  expelled.  After-]>ains 
were  felt  in  the  tumor.  She  made  a  good  recovery,  and  the  swelling  dimin- 
ished and  became  less  ])ainful. 

It  must  not  be  forgotten  that  the  omentum  and  the  intestines  may  also  enter 
into  the  hernial  sac,  and  so  tend  to  mask  the  symptoms  arising  from  the  pres- 
ence of  the  ovary. 

Diagnosis.— The  diagnosis  of  hernia  of  the  ovary  is  easy  hi  the 
presence  of  the  characteristic  signs  detailed,  and  difiicult  in  their  absence. 


488 


THE    RADICAL   CURE    OF   HERNIA. 


Tlie  history  shows  that  the  patient  has  had  a  small  ovoid  lump  in  the 
groin,  it  may  be  from  childhood.  At  the  time  of  puberty  the  lump  becomes 
suddenly  painful  at  the  menstrual  periods,  when  it  swells  decidedly.  It  is 
hard,  generally  movable,  and  sensitive  on  pressure.  If  it  has  existed  since 
childhood,  the  fact  that  the  enlargement  is  bilateral  is  especially  suggestive  of 
ovarian  hernia. 

Upon  making  an  examination  of  the  genitals,  a  malformation  will  often  be 
found. 

All  of  these  peculiarities  serve  to  distinguish  an  ovarian  hernia  from  an 
epiplocele  (omental  hernia),  enterocele,  lipoma,  or  an  encysted  peritonitis. 


^'■^' 

:  \j 

Tube 

\^M 

W 

Ov.. 
\ 

[^; 

]\cl.lig— ^. 


y  Yioauie    in 
nguinal  canal  . 


Fig.  555. — I'akti.m,  IIkhnia  ok  the  Left  Ovary. 

The  sliort  tube  close  by,  lying  over  the  superior  strait,  has  no  uterine  connection.     The  uterus  is  dis- 
placed markedly  to  the  rigfit  side.     The  right  ovary  and  tube  are  normal.     Nov.  1,  1897. 


Upon  making  an  examination  of  internal  pelvic  organs,  which  would  better 
be  done  under  anesthesia,  in  addition  to  the  characteristic  sign  afforded  by  the 
malformation  of  the  vagina  and  uterus  in  other  cases,  in  hernia  of  one  side  the 
uterus  is  found  with  one  horn  pulled  decidedly  toward  that  side  (torsion) ;  upon 
pulling  on  the  cervix  with  a  tenaculum  forceps  the  inguinal  tumor  is  displaced, 
and  on  letting  the  cervix  go  it  returns  again  to  its  place.  Further,  a  bimanual 
examination  shows  the  absence  of  the  ovary  from  the  side  on  which  the  hernia 
is  found,  and  if  the  uterus  is  pulled  down  and  the  utero-ovarian  ligament  is  felt 
it  can  then  ])0  traced  out  toward  the  inguinal  canal. 


OVAKIAX   HEKNIA.  489 

"When  there  is  a  double  ovarian  hernia  with  a  well-developed  uterus,  the 
latter  is  pulled  up  and  lixed  behind  the  pubis,  much  as  if  there  had  been  an  ex- 
treme shortening  of  the  round  ligaments. 

As  Cruveilhier  has  pointed  out,  the  occasional  presence  of  the  uterus  or  a 
part  of  it  in  the  sac  is  due  to  its  organic  connection  with  the  tube  and  the  ovary, 
which  descend  first  with  a  part  of  the  broad  ligament,  and  if  the  traction  is 
continued  it  is  only  a  question  of  the  size  of  the  orifice  of  the  sac  and  the  mo- 
bility of  the  uterus  how  soon  the  latter  will  enter  it. 

F.  Krug  {Amer.  Jour.  Ohs..,  1890,  p.  606)  made  a  diagnosis  of  hernia  of 
the  uterus  before  operation  in  a  young  woman  eighteen  years  old  who  had  a 
swelling  five  inches  in  diameter  in  the  left  inguinal  region  in  which  two  hard, 
movable  masses  could  be  felt,  one  large  and  pear-shaped,  and  the  other,  distinct 
from  it,  about  the  size  of  a  walnut.  The  cervix  was  found  close  behind  the 
symphysis,  and  any  movement  given  to  it  was  at  once  communicated  to  the 
pear-shaped  mass.  This  mass  could  also  be  pushed  out  of  the  canal  into  the 
abdomen,  and  on  further  investigation,  grasping  it  on  all  sides  with  the  thumb 
and  the  index  finger  of  one  hand  in  the  vagina  and  in  the  rectum,  and  the  other 
hand  above  over  the  inguinal  canal,  the  uterus  could  be  handled  so  as  to 
leave  no  doubt  as  to  its  identity  and  its  jDresence  in  the  canal ;  the  diagnosis  was 
verified  by  operation. 

Treatment . — The  treatment  is  similar  to  that  of  other  inguinal  hernise. 
If  the  presence  of  the  tumor  is  the  occasion  of  persistent  or  severe  periodical 
discomforts  the  inguinal  canal  should  be  laid  open,  the  ovary  and  the  tube,  and 
it  may  be  the  uterus,  exposed,  any  adhesions  freed,  and  the  organs  returned  to 
the  pelvis,  the  sac  removed,  and  the  inguinal  canal  closed  in  the  manner  de- 
scril)ed. 

If  tlie  ovary  is  much  enlarged  or  has  become  converted  into  a  tumor  of  any 
sort  it  will  then  be  best  to  pull  it  out  and  tie  off  the  broad  ligament  carefully 
with  a  number  of  fine  silk  sutures  and  to  remove  the  ovary,  letting  the  pedicle 
drop  back  into  the  abdomen. 

In  one  of  my  cases  of  hernia  of  one  ovary  (see  Fig.  555)  the  left  ovary  en- 
tered the  canal  only  partially,  in  such  a  way  as  to  produce  a  marked  constriction 
between  the  middle  and  the  outer  third  at  a  point  corresponding  to  the  internal 
inguinal  ring.  There  had  been  no  symptoms  whatever  referable  to  the  ovary, 
and  on  opening  the  abdomen  I  found  the  uterus,  contrary  to  the  rule,  markedly 
displaced  toward  the  right  side,  with  a  well-developed  right  tube,  ovary,  and 
round  ligament,  and  a  fairly  well-developed  right  uterine  bot'v;  but  the  left 
cornu  was  anomalous  and  communicated,  by  what  appeared  to  be  a  long  round 
ligament,  with  the  inguinal  canal,  in  which  lay  a  part  of  the  well-develo])ed 
ovary  and  beyond  it  a  little  fleshy  nodule,  looking  like  a  rudimentary  uterus. 
The  left  uterine  tube  was  short,  and  ended  in  a  little  blunt  stump,  as  shown. 
I  pulled  the  ovary,  with  the  nodule,  out  of  the  canal,  with  the  intention  of 
sewing  up  the  internal  inguinal  ring  from  within,  but  it  took  so  much  traction 
to  get  it  out  that  I  could  not  sew  uj)  the  ring  without  severing  its  connections, 
so  I  concluded  the  operation  by  stitching  the  ovary  on  all  sides  to  the  ring,  in 
74 


490 


THE    RADICAL    CURE    OF   HERNIA. 


the  position  on  whicli  I  found  it,  so  as  to  prevent  the  entrance  of  any  of  the 
other  abdominal  viscera  into  the  canal. 

The  patient  recovered  and  has  suffered  no  inconvenience  from  her  condition. 

Femoral  Hernia. — This  variety  of  hernia  is  comparatively  common  in  women, 
and  is  peculiarly  liable  to  strangulation  ;  over  60  per  cent  of  the  cases  were 
strangulated,  and  three  of  these  were  gangrenous,  according  to  Bloodgood's  sta- 
tistics from  the  Johns  Hopkins  Hospital. 


A. it  .  -.^p.  5p 


■.^ 


.  / 


IIB    •       Ki'-i  ;  rn\     r>  <'P' 


►'Saphenous      op' 


Femoral  cing" 


Femoral  (heffi'a 


'.j:ggrrt::, 


Fig.  550. — Left  Fp;moral  IIeknia. 

Showint;  the  characteristic  form  and  position  of  the  hernial  sac  beneath  Poupart's  ligament.  A  small 
gland  is  seen  on  the  upper  outer  border  of  the  sac.  On  the  rijrht  side  the  toposrraphy  of  a  femoral  hernia 
IS  shown;  the  arrow  indicates  the  direction  taken  by  the  hernia  heneath  Poupart's  ligament  and  out  through 
the  saphenous  opening.     The  various  important  landmarks  are  shown.     II.     Ward  II.     Nov.  20,  1897. 

There  are  various  methods  of  treatment  of  femoral  hernia,  and,  miless  the 
hernia  is  large,  they  are  all  followed  by  a  large  percentage  of  successes. 

In  gynecological  cases  in  which  I  have  had  occasion  to  open  the  abdomen 
for  some  pelvic  disease  I  have  found  stitching  the  sac  from  within  successful. 


FEMORAL   HERNIA.  491 

After  the  abdomen  is  opened  I  locate  the  femoral  ring,  and  then  with  the 
abdominal  incision  well  lifted  up  with  retractors,  the  pelvis  being  elevated,  I  am 
able  to  close  effectually  the  femoral  ring  without  great  difficulty.  As  a  rule,  the 
hernial  sac  is  small,  and  I  make  no  attempt  to  dissect  it  out.  The  first  mattress 
silk  suture  is  introduced  from  above  down  through  Poupart's  ligament,  close  to 
the  external  iliac  vein,  which  can  be  seen  and  felt,  then  on  through  the  pubic 
portion  of  the  fascia  lata,  and  back  again  through  Poupart's  ligament.  One  or 
two  sutures  is  sufficient  to  close  the  ring  efEectualiy.  The  utmost  care  must  be 
taken  to  avoid  injuring  the  external  ihac  vein. 

In  cases  where  the  abdomen  is  not  opened  an  external  incision  is  made  over 
the  hernia,  usually  perpendicular  to  Poupart's  ligament,  and  extending  up  to 
this  structure,  but  not  dividing  it.  After  exposing  the  sac,  it  is  hgated  in  the 
same  way  as  an  inguinal  hernia,  and  excised.  One  mattress  suture  is  passed 
through  Gimbernat's  ligament  above  and  the  pubic  portion  of  the  fascia  lata 
below.     Care  must  be  observed  not  to  cut  or  prick  the  saphenous  vein. 

A  satisfactory  way  of  treating  femoral  hernia  is  to  excise  the  sac  as  de- 
scribed above,  and  then  to  pack  a  small  piece  of  gauze  into  the  canal,  removing 
it  gradually  within  ten  days  ;  this  causes  the  canal  to  close  by  scar  tissue. 

In  one  of  my  eases  (H.  S.,  5111,  March  20,  1897),  after  opening  the  abdo- 
men I  slipped  a  sterilized  glass  ball  into  the  right  femoral  sac,  which  it  filled, 
and  then  sutured  the  peritoneum  over  it  in  two  layers.  Eecovery  followed 
without  any  discomfort,  and  there  has  been  no  tendency  of  the  hernia  to  return 
since.  The  ball  can  be  felt  bimanually  with  two  fingers  pushing  up  through 
the  anterior  vaginal  wall,  while  the  other  hand  pushes  down  from  above  just 
over  the  right  Poupart's  ligament. 


CHx\PTER  XXXVI. 

INTESTINAL   COMPLICATIONS. 

1.  The  commonest  intestinal  complications  found  in  gynecological  work  involve:  1.  Rectum,  sig- 

moid, and  ileum  (Groups  D  and  E).  2.  Vermiform  appendix  and  head  of  the  colon.  3. 
Adhesions  are  found  high  up  in  the  abdomen,  in  ovarian  cysts,  and  fibroid  uteri.  4.  Gen- 
eral adhesions  of  bowels  among  themselves. 

2.  Kinds  of  intestinal  complications:  1.  Flat  or  velamentous  adhesions.     2.  Fistulae.     3.  Stric- 

tures.    4.  Peritoneal  bands. 

3.  Treatment  of  adherent  bowel :  1.  By  clipping  adhesions  with  scissors.     2.  By  leaving  a  piece  of 

an  ovary  or  fibroid  tumor  on  the  bowel.  3.  Special  cases  cited  of  adhesions  to  uterus,  to 
myomata.  to  ovarian  cysts,  to  pelvic  abscesses. 

4.  Removal  of  the  vermiform  appendix. 

5.  Suture  of  the  intestines :  1.  Fibrous  coat  of  the  intestine;  ileum,  cecum,  and  rectum  compared. 

2.  Cleanliness  in  operating.  3.  Tear  of  the  peritoneal  muscular  coat.  4.  Operation  when 
the  lumen  of  the  bowel  is  opened.     5.  Operation  when  the  rectum  is  injured. 

6.  Anastomoses:  1.  Side-to-side  anastomosis.     2.  End-to-end  anastomosis.     3.  End-to-side  anasto- 

mosis.    4.  Ileo-eecal  anastomosis.     5.  Anastomosis  buttons. 

7.  Artificial  anus — colostomy. 

Even  tlie  gynecologist  who  practices  his  specialty  in  the  narrowest  sense 
and  confines  his  attention  to  the  pelvic  organs  alone  is  liable  in  the  course  of 
any  abdominal  operation  to  meet  with  intestinal  complications  associated  with 
the  gynecological  aihnent,  and  he  is  particularly  liable  to  meet  with  a  well- 
defined  group  of  intestinal  complications  which  stand  in  the  direct  relation  of 
effect  and  cause  to  the  disease  he  has  undertaken  to  treat.  It  is  absolutely 
necessary,  therefore,  for  the  well-equipped  gynecologist  to  be  prepared  to  meet 
all  such  emergencies,  and  to  know  by  what  j^lans  he  may  sometimes  avoid  injur- 
ing the  bowel,  or  how  to  make  a  necessary  injury  as  limited  as  possible  in  its 
extent,  and  how,  on  the  other  hand,  to  deal  with  the  gravest  intestinal  lesions 
which  can  occur. 

The  commonest  and  the  most  serious  complications  are 
found  associated  with  pelvic  inflammatory  affect  ions,  and 
involve  those  portions  of  the  intestinal  tract  which  lie  normally  within  the  pel- 
vis or  above  its  brim  and  in  contact  with  the  inflamed  pelvic  structures — that  is  to 
say,  the  rectum,  the  lower  part  of  the  sigmoid  flexure,  and  the  ileum,  which  natu- 
rally drops  into  the  posterior  pelvis  or  lies  like  a  lid  on  top  of  it  (Groups  D  and 
E  in  Fig.  21,  Vol.  I,  p.  51) ;  next  in  order  come  the  vermiform  appendix,  the 
head  of  the  colon,  and  the  displaced  transverse  colon. 

In  the  case  of   large   tumors  encroaching  on  the  upper  abdominal 

cavity,  such  as  dermoid  cysts,  and  some  ovarian  cysts,  particularly  those  with  a 

twisted  pedicle  and  those  which  are  suppurating,  adhesions  may  be  contracted 

with  intestines  far  higher  up  than   usual,  involving   the  transverse  colon  and 

492 


Fio.  557.— Method    of    dealing    with    Intestinal    Ai.iiemi-.v.s    whkhe   an   Interval    can    be    developed 

BETWEEN    THE    BoWEL    AND    THE    ADHERENT    SlRFACE    BV    SLIGHT    TraCTION. 

As  each  adhesion  is  divided,  tlie  next  one  beyond  it  is  stretched  for  division. 


VARIOUS    KINDS    OF    IXTESTIXAL    COMPLICATIONS.  493 

Groups  A,  B,  and  C  {ut  sujjra).  The  same  thing  is  true  of  large  fibroid  tumors 
in  the  abdomen.  Under  these  circumstances  the  area  covered  bj  the  intestinal 
adhesions  is  often  far  greater  than  is  possible  in  disease  limited  to  the  pelvis. 

In  cancer  of  the  ovarj  and  in  tuberculosis  of  pelvic  origin  adhesions  be- 
tween adjacent  loops  of  intestines  and  the  diseased  area  are  common  concomi- 
tants, but  these  conditions  rarely  admit  of  any  operative  treatment,  nor,  indeed, 
do  they  call  for  it. 

Another  form  of  intestinal  adhesions  which  demands  particular  notice  is  a 
more  or  less  general  agglutination  of  the  bowels  among  them- 
selves, the  sequel  of  a  peritoneal  storm  which  has  passed  over,  the  patient 
surviving  the  peritonitis,  which  leaves  the  bowels  everywhere  mutually  attached. 
When  the  abdominal  cavity  is  opened,  the  separate  loops  are  often  diflicult  to 
distinguish,  but  in  their  place  is  found  what  appears  to  be  a  flattish  red  sac, 
presenting  over  its  surface  numerous  slight  irregularities  and  whitish  streaks ; 
this  sac,  without  careful  study,  might  easily  be  mistaken  for  a  collapsed  tumor. 
By  watching  a  little  while,  or  tapping  the  sac  smartly  with  the  finger,  a  vermicular 
wave  is  started  which  shows  the  presence  of  the  intestine.  Sometimes  these 
adhesions  are  loose  and  velamentous,  and  would  be  easily  separated  if  it  were 
not  for  their  great  extent. 

An  inquiry  into  such  a  patient's  history  will  often  show  that  she  has  not  suf- 
fered in  any  way  from  intestinal  cramps  or  obstruction.  I  have  seen  several 
cases  of  tubercular  peritonitis  where  all  the  intestines  were  adherent  and  ap- 
peared as  if  covered  with  a  thick  sheet  of  wet  gray  blotting  paper,  and  yet  there 
were  no  signs  of  any  interference  with  the  function  of  the  bowel.  The  rule 
may  therefore  be  laid  down  that  when  the  intestines  are  widely  ad- 
herent, without  displacement  of  any  of  the  loops,  opera- 
tive interference  is  not  always  necessary.  On  the  contrary,  a 
well-intended  interference  in  these  cases  may  bring  about  the  very  result  the 
operator  wishes  to  avoid,  for  the  raw  separated  surfaces  easily  form  new  attach- 
ments, and  one  or  more  loops  of  the  bowel  may  be  caught  the  second  time 
and  detained  in  a  vicious  position. 

The  symptoms  of  obstruction  or  intestinal  tormina  must  be  the  gauge  by 
which  to  determine  whether  extensive  adhesions  ought  or  ought  not  to  be  sepa- 
rated. 

Various  Kinds  of  Intestinal  Complications. — T  he  kinds  of  intestinal 
complications  met  with  are  adhesions,  either  flat  or  vela- 
mentous, peritoneal  bands,  intestinal  strictures,  anasto- 
moses between  the  loops  of  bowels,  and  fistulae. 

Adhesions  are  more  apt  to  be  found  as  the  remains  of  more  or  less  general- 
ized attacks  of  peritonitis  ;  if  the  interval  between  the  attack  and  the  operation 
is  but  a  short  one,  the  adhesions  will  be  found  far  more  extensive  than  at  a  later 
date,  provided  the  cause  has  ceased  to  act,  for  even  an  extensive  peritonitis  ^vith 
widespread  adhesions  may,  after  a  few  months,  leave  scarcely  any  trace  of  its 
existence  behind,  and  any  lingering  adhesions  will  be  most  apt  to  be  found  near 
the  focus  of  the  disease. 


494  INTESTINAL   COMPLICATIONS. 

The  complete  manner  in  which  extensive  peritoneal  adhesions  may  clear  up 
has  often  been  demonstrated  at  an  operation  for  a  ventral  hernia  arising  from 
the  use  of  a  gauze  drain  after  an  abdominal  operation.  It  is  well  known  that 
extensive  adhesions  form  around  such  drains  if  they  are  left  in  for  a  few  days, 
and  yet  upon  opening  the  abdomen  subsequently  to  operate  upon  the  hernia 
follo\ving  the  use  of  the  drain,  the  peritoneum  has  been  repeatedly  found  en- 
tirely free  from  adhesions  of  any  sort. 

The  same  observation  has  been  made  regai'ding  the  adhesions  surrounding  the 
drain  used  after  removal  of  the  vermiform  appendix,  and  even  in  the  case  of  the 
extensive  adhesions  of  a  tubercular  peritonitis. 

In  cases  of  pelvic  inflammatory  disease  characterized  by  repeated  attacks  of 
peritonitis,  between  the  attacks  some  of  the  plastic  lymph  is  absorbed,  but  there 
is  each  time  a  residuum  which  forms  adhesions  about  the  diseased  tube  or  ovary, 
continually  becoming  denser. 

On  the  other  hand,  in  cases  of  fresh  acute  peritonitis  the  formation  of  adhe- 
sions progresses  at  an  equal  pace  with  the  extension  of  the  disease.  When  the 
peritonitis  is  old,  and  urgent  symptoms  arise,  everything  may  be  done  by  opera- 
tion to  divide  the  adhesions  and  relieve  the  disease,  but  in  the  recent 
cases,  while  the  inflammation  is  acute  and  progressive, 
unless  the  symptoms  are  most  pressing,  as  a  rule  the  adhe- 
sions should  not  be  dealt  with  directly,  but  the  effort  should  be 
made  by  cleansing  the  abdomen,  or  washing  it  out,  or  if  need  be,  by  extensive 
vaginal  drainage,  to  cut  short  the  infective  pi'ocess  or  to  diminish  its  intensity. 

The  manner  in  which  the  adhesions  surround  a  sej^tic  focus  in  the  pelvia 
clearly  shows  that  the  agglutination  of  the  loops  of  the  intestines  is  one  of  na- 
ture's safeguards  against  any  sudden  invasion  of  septic  material  into  the  peri- 
toneal cavity,  for  we  constantly  find  a  shading  off  in  the  density  of  the  adhe- 
sions, which  are  lightest  at  a  distance  from  the  focus,  and  with  any  extension  of 
the  septic  process  a  barrier  of  this  sort  is  kept  in  front  as  an  advance  guard, 
efficiently  protecting  the  general  abdominal  cavity.  In  old  cases  Math  general 
pelvic  adhesions  a  barrier  of  dense  adhesions  is  sometimes  found  covering  in  the 
pelvis — so  dense  that  the  bowel  can  not  be  detached  without  tearing  it;  below 
this  barrier  protecting  the  abdominal  cavity,  the  adhesions  may  be  so  much 
lighter  that  the  organs  once  exposed  can  be  freed  without  special  difficulty  or 
risk  of  rupture.  Knowing  this  fact,  it  is  easy,  for  example,  to  enucleate  tlie 
diseased  adherent  structures  on  one  side  by  first  cutting  across  the  cervical  por- 
tion of  the  uterus  and  then  stripping  them  loose  from  below  upward,  instead 
of  following  the  usual  method  of  releasing  them  from  above  downward. 

Loose  V  e  1  a  ra  e  n  t  o  u  s  and  fibrinous  adhesions  are  oftenest 
found  and  most  widesj^read  in  tlieir  distribution,  as  well  as  the  least  dangerous. 
They  are  most  troii])lesome  when  limited  to  a  particular  region  or  to  a  few  coils 
of  intestines ;  in  such  cases  the  interference  with  peristalsis  may  be  marked,  and 
the  patient  may  suffer  constantly  from  colic.  Outside  of  the  pelvis  such  areas 
of  adhesions  are  oftenest  found  in  the  right  lower  abdomen,  with  the  vermiform 
appendix  as  a  center.     If  this  occurs  as  the  sequel  of  an  operation,  the  ho])e 


VARIOUS    KIXDS    OF    ISTESTIXAL    C05IPLICATI0XS.  495 

may  always  be  indulged  that  with  patience  and  the  lapse  of  time  absorption  will 
take  place  and  the  pain  cease  ;  I  have  seen  this  happen  repeatedly.  At  the 
same  time  it  is  sometimes  one  of  the  nicest  points  in  abdominal  surgery  to  dis- 
tinguish between  such  a  case,  where  there  may  be  a  constant  but  slow  improve- 
ment, and  one  which  will  not  improve,  where  an  operation  is  ultimately  inevi- 
table and  the  patient  is  losing  strength  with  the  delay.  Dense  flat  adhesions  of 
the  bowel  are  found  affecthig  those  loops  of  intestines  which  lie  directly  in  con- 
tact ^Hth  a  highly  septic  focus,  and  the  destructive  alterations  in  the  lumen  of 
the  intestine  are  often  so  great  that  a  detachment  without  opening  its  lumen 
may  be  impossible.  In  many  instances  the  history  of  the  case  shows  that  such 
adhesions  mark  the  spot  where  an  abscess  has  at  some  time  ruptured  through 
and  discharged  by  the  bowel ;  in  other  cases  again  the  abscess  is  actually  on  the 
point  of  discharging,  and  but  a  thin  diaphragm  in  the  intestinal  wall  prevents 
the  pus  from  escaping,  and  all  that  may  be  wanted  to  break  the  barrier  is  the 
pressure  of  the  operator's  hand  as  he  grasps  the  abscess  to  enucleate  it. 

In  this  way  fistula  arise,  and  the  question  whether  or  not  they  will  remain 
permanent  depends  upon  the  size,  position,  and  character  of  tlie  contents  of  the 
abscess.  Fistulse  of  this  sort  commonly  discharge  directly  into  the  bowel,  and 
are  fortunately  lacking  the  long,  thick-walled  sinus  adherent  on  all  sides  some- 
times found  in  other  intestinal  fistulae. 

In  two  thousand  celiotomies  I  have  seen  three  instances  of  fistulse  opening 
into  the  cecum ;  one  was  a  large  suppurating  ovarian  monocyst,  another  a  small 
dermoid  cyst,  and  the  third  a  pelvic  abscess  densely  adherent  in  every  direction. 
(E.  B.,  Feb.  15,  1896,  ]S^o.  1116^). 

In  two  instances  (one  of  them  M.  L.  oST.,  1824,  March  1,  1893)  I  have  seen 
a  spontaneous  anastomosis  between  loops  of  the  ileum,  looking  like  a  little  l)ridge 
of  bowel  between  them  not  more  than  a  centimeter  in  diameter  and  only  a  few 
millimeters  long ;  in  dividing  this  bridge,  the  mucosa  of  the  bowel  pouted  out 
on  each  side  from  an  opening  3  or  4  millimeters  in  diameter. 

Stricture  of  the  bowel  caused  by  a  neoplasm  or  the  result  of  an 
old  chronic  ulceration  may  be  found  at  any  point.  I  have  seen  long  tubular 
strictures  in  the  ileum  near  the  valve,  and  again  in  the  rectum  at  any  point 
from  the  brim  of  the  pehas  down  to  the  rectal  ampulla.  A  remarkable  annular 
stricture  caused  by  the  constant  compression  of  the  neck  of  the  sac  of  an  in- 
carcerated ventral  hernia  is  figured  in  Chapter  XXXVII. 

Stricture  of  the  rectum  between  the  u  t  e r  o - s a c r a  1  folds 
and  just  above  them  is  so  often  found  associated  with  pel- 
vic inflammatory  diseases  that  it  must  be  looked  upon  as 
peculiarly  a  gynecological  ailment.  When  the  inflammation  on 
one  side  extends  across  the  pelvis,  or  when  both  sides  are  involved  and  abut 
against  each  other  behind  the  uterus,  the  distensibility  of  the  bowel  is  often 
interfered  with. 

The  stricture  may  be  seen  by  putting  the  patient  in  the  knee-chest  posture 
and  inspecting  the  rectum  from  the  ampulla  up:  just  back  of  the  cervix  the 
bowel  presents  a  contracted  opening  often  not  much  more  than  a  centimeter  in 


496  INTESTINAL   COMPLICATIONS. 

diameter ;  on  making  a  digital  examination,  as  the  finger  leaves  the  ampulla  it 
enters  a  rigid  contracted  tube.  The  rule  is  for  a  rapid  recovery  to  take  place 
when  the  disease  is  removed,  but  when  all  the  coats  of  the  rectum  have  been  in- 
volved in  the  inflammatorv  process  the  stricture  may  remain  permanent,  and  it 
is  remarkable  how  well  a  woman  can  get  along  with  a  stricture  of  the  rectum 
which  is  not  more  than  3  or  4  millimeters  in  diameter. 

Dense  or  delicate  fibrous  bands  stretching  from  one 
part  of  the  abdomen  or  pelvis  to  another  part,  or  from  intes- 
tine, uterus,  l)ladder,  or  omentum  to  the  abdominal  or  pelvic  walls,  are  not 
often  found.  Their  presence  is  always  fraught  with  the  danger  of  an  incarcera- 
tion and  strangulation  of  a  loop  of  the  bowel  beneath  the  band  ;  to  obviate  this 
risk  all  such  l)ands  must  be  divided. 

Treatment  of  Adherent  Bowels. — The  question  how  to  deal  with  adherent 
bowels  is  of  the  utmost  importance,  and  one  in  which  the  skill  and  experience 
of  the  operator  may  be  brought  into  the  fullest  play,  to  avoid  dangerous  acci- 
dents, or  to  deal  with  such  accidents  when  they  do  occur ;  the  greatest  risk,  that 
of  infection,  arises  when  the  cavity  of  the  bowel  is  opened. 

I  shall  speak  first  of  the  methods  of  avoiding  injury  to  the 
wall  of  the  intestin e — that  is,  of  avoiding  the  necessity  of  using  an  intes- 
tinal suture — and  second  of  the  various  ways  of  suturing  the  bowel 
when  it  is  injured. 

Slight,  superficial,  and  velamentous  adhesions  can 
always  be  severed  by  clipping  them  with  scissors,  or  if 
there  is  not  enough  of  an  interval  between  the  adherent 
organs  to  (;ut  safely,  one  may  be  formed  by  making  trac- 
tion on  the  bowel.  In  this  way  a  flat  adhesion  may  be 
made  to  develop  an  interval  of  a  few  millimeters,  in  which 
it  may  l)e  cut  with  safety  (see  Fig.  557). 

In  detaching  a  womb  adherent  in  this  way  to  the  rectum,  the  uterus  is 
pushed  forward  with  the  middle  finger  and  the  rectum  is  drawn  back  with  the 
index  finger,  developing  the  interval,  while  the  other  hand  does  the  cutting  with 
the  scissors.  A  flat  adhesion  which  will  not  pull  out  may  often  still  be  severed 
by  a  careful  dissection  with  a  scalpel  or  the  very  tip  ends  of  the  scissors  snip- 
ping little  bits  of  tissue  at  a  time. 

Denseadhesions  which  are  not  amenable  to  these  sim- 
pler plans  of  treatment  may  often  be  handled  best  by  leav- 
ing a  piece  of  the  organ  on  the  bowel  covering  the  ad- 
herent area. 

The  operator  may  need  to  deal  in  this  way  with  adhesions  (1)  to  the  uterus, 
(2)  to  myomata,  (3)  to  ovarian  cysts,  and  (4)  to  pelvic  abscesses. 

1.  When  a  dense  adhesion  exists  between  the  posterior  wall  of  the  uterus 
and  the  intestine,  and  it  can  not  be  freed  without  risk  of  opening  the  bowel, 
the  best  way  to  deal  with  it  will  be  the  following,  which  I  have  adopted  in 
several  instances  with  success  :  After  freeing  the  bowel  on  all  sides  down  to  the 
fixed  point,  which  is  usually  a  small  area  not  more  than  a  centimeter  or  two  in 


TREATMENT   OF   ADHEREXT   BOWELS.  497 

diameter,  an  incision  into  the  uterine  wall  is  made  on  all  sides  close  to  the  ad- 
hesion, about  a  millimeter  in  depth,  and  then  bj  careful  dissection  with  a  sharp 
scalpel  a  thin  layer  of  the  uterus  is  dissected  o&  and  left  adhering  to  the  bowel, 
which  is  now  free.  The  oozing  from  the  raw  spot  on  the  bowel  is  always 
trifling,  and  that  from  the  uterus  may  be  checked  by  a  few  interrupted  catgut 
sutures  passed  so  as  to  draw  the  peritoneal  edges  of  the  wound  together,  and 
tied  tight  enough  to  control  the  flow. 

2.  When  the  bowel  presents  a  dense  adhesion  to  any  part  of  a  mvomatous 
tumor  the  same  jDrinciple  may  be  applied  with  great  freedom  by  dissecting  off 
a  thin  layer  of  the  capsule  of  the  tumor  and  leaving  it  adherent  to  the  intes- 
tme.  There  need  be  no  fear  of  the  tumor  developing  again  from  this  area, 
for  in  the  first  place  such  a  piece  of  the  tumor  has  no  power  whatever  of 
regeneration,  and,  moreover,  the  capsule  is  usually  made  up  of  the  stretched- 
out  and  muscular  envelope  derived  from  the  uterine  tissue,  and  not  of  the 
tumor  proper. 

3.  In  the  case  of  most  ovarian  cysts  the  dense  white  outer  capsule  of  the 
tumor  may  be  stripped  off  and  left  attached  here  and  there  to  densely  adherent 
coils  of  the  intestines  without  risk ;  this  would  not  be  safe,  however,  with  pa- 
pillary and  malignant  tumors. 

A  case  I  am  about  to  cite  serves  well  to  illustrate  the  application  of  this  life- 
saving  principle  on  an  extensive  scale.  The  patient  (E.  B.  L.,  -4946,  Jan.  20, 
1897),  a  feeble  elderly  woman,  was  suffering  from  an  ovarian  tumor  filling 
the  lower  abdomen  and  about  the  size  of  a  six  months'  pregnancy.  On  open- 
ing the  abdomen,  about  30  centimeters  of  the  ileum  was  found  plastered  on 
top  of  the  tumor  from  the  ileo-cecal  valve  across  to  the  left  side ;  the  adhesion 
was  a  flat  one,  involving  the  inferior  half  of  the  l)0wel,  and  so  intimate  that  any 
attempt  at  separation  would  have  injured  the  bowel  and  necessitated  a  resection 
of  the  entire  adherent  portion.  With  a  view  to  ligating  the  main  vascular 
trunks  of  the  tumor,  and  so  preventing  the  hemorrhage  from  adhesions,  I  began 
by  enucleating  the  pelvic  portion  of  the  tumor  from  a  bed  of  adhesions  and 
tying  its  pedicle  off  at  the  pelvic  brim  and  the  uterine  cornu ;  in  the  course  of 
this  enucleation  700  cubic  centimeters  of  thick  yellow  pus  were  evacuated,  and 
the  collapsed  sac  was  finally  drawn  out  of  the  abdominal  incision,  adherent  only 
around  the  brim  of  the  posterior  part  of  the  pelvis,  and  over  the  great  vessels 
at  the  sides  and  above  the  brim,  up  as  far  as  the  mesentery,  to  which  it  was  also 
densely  adherent  from  the  vertebral  column  out  to  the  bowel,  which  was  spread 
out  over  it  as  described.  As  these  adhesions  could  not  be  separated  without 
risk  of  injuring  beyond  repair  such  vital  structures  as  the  aorta,  vena  cava, 
superior  hemorrhoidal  and  mesenteric  vessels,  as  well  as  the  ileum,  I  overcame 
the  difficulty  by  leaving  in  all  of  the  adherent  outer  capsule  of 
the  tumor.  To  do  this,  I  made  a  circular  incision  on  all  sides  about  a  centi- 
meter from  the  attached  edge  and  from  a  millimeter  to  a  millimeter  and  a  half 
deep,  continuing  the  dissection  bluntly  with  the  handle  of  the  scalpel  back 
under  the  mesentery  from  below  and  from  above,  until  the  entire  inner  surface 
of  the  cyst  was  removed  in  one  piece. 


498 


INTESTINAL   COMPLICATIONS. 


The  tendency  on    the   part  of   tlie  capsule  of   the   tumor  to  tear  through 
into   the   more   superficial   layers   was   checked   by   the   frequent   use   of   the 


Fig.  558. — First  Step  in  the  Operation  for  Appendicitis. 

The  appendix  and  niescnteriolum  freed  and  the  first  ligature  applied  eontrollinir  the  vessels  of  the  mes- 
enteriolum,  exclusive  of  the  branch  which  goes  to  the  base  of  the  appendix.  The  incision  is  made  in  the 
direction  of  the  arrow. 

scissors  or  scalpel.  The  cap  of  the  outer  surface  of  the  tumor — that  is  to 
say,  the  albuginea  of  the  ovary,  which  was  left  behind — was  as  large  as  an 
ordinary  sleeping-cap;  it  did  not  bleed  at  all,  and  was  simj^ly  dropped  into 
the  abdomen  with  its  anterior  and  posterior  walls  lying  in  contact,  and  the 
abdomen  was  closed  without  a  drain.  The  convalescence  was  entirely  undis- 
turbed. 

4.  When  the  bowel  adheres  to  a  pelvic  abscess  the  same  plan  of  treatment 
may  be  applied ;  in  this  group  of  cases,  however,  it  will  often  be  necessary  to 
cut  out  the  entire  thickness  of  the  abscess  wall  over  an  area  corresponding  to 
the  adhesion  to  the  bowel,  and  then  either  to  scrape  off  the  inner  lining  of  the 
mem])rane  or  to  burn  it  off,  so  as  to  eliminate  the  risk  of  infection  from  this 
source. 


REMOVAL    OF   THE    VEKMIFORM    APPENDIX. 


499 


Removal  of  the  Vermifonn  Appendix. — In  every  abdominal  section 
tlie  vermiform  appendix  should  he  picked  ii])  and  in- 
spected and  its  condition  noted  in  writing  on  the  patient's 
history. 

The  frequency  of  the  occurrence  of  adliesions  of  the  vermiform  appendix  to 
inflammatory  structures  in  the  pelvis  appears  to  me  to  be  one  of  the  strongest 
indications  for  the  abdominal  route  in  deahng  with  cases  of  this  class. 

In  the  series  of  one  hundred  hystero-salpingo-oopho- 
rectomies,  the  vermiform  appendix  was  adherent  in 
twenty-seven  cases,  and  in  seven  cases  required  removal 
on  account  of  the  extensive  disease  in  this  structure. 

In  order  to  remove  the  appendix  it  is  freed  and,  with  the  head  of  the  colon, 
brought  outside  the  abdominal  incision  and  laid  on  a  gauze  pad.  The  appendix 
is  then  lifted  up  near  the  colon  and  its  mesentery  tied  off  with  one  or  two  single 
fine  silk  ligatures,  including 
all  its  vessels;  the  mesen- 
teriolum  is  then  cut  through 
down  to  the  root  of  the  ap- 
pendix. A  circular  incision 
is  now  made  through  the 
peritoneum  surrounding  the 
appendix  about  2  centime- 
ters from  the  large  bowel, 
and  by  pulling  on  its  lower 
end  and  using  the  point  of 
the  knife  or  a  little  blunt 
instrument  to  peel  back  the 
peritoneum,  a  cuff  1  centi- 
meter long  is  turned  up 
onto  the  colon.  The  mus- 
cular and  mucous  coats  are 
now  tied  tightly  with  fine 
silk  close  under  the  reflected 
cuff  and  close  to  the  co- 
lon, and  another  ligature  is 
placed  lower  down  after 
milking  back  its  contents, 
so  as  to  prevent  any  escape 
of  fecal  matter  upon  sever- 
ing the  appendix.  The  ap- 
pendix is  now  divided  half 
a  centimeter  beyond  the  proximal  ligature.  Tiie  free  end  is  removed  or  the  end 
adhering  to  the  tumor  is  carefully  wrapped  in  gauze  and  drt)pped  for  a  time. 
The  stump  shows  a  small  tract  of  everted  mucosa  ])(»uting  beyond  its  ligature; 
this  is  cleansed  with  a  bit  of  cotton  and  sterilized  with  pure  carbolic  acid,  taking 


Fig.  559. — Second  Stkp  in  the  Opkkation  wr  AppENKiriris. 
The  mcsenteriolum  cut  tlirouirli  and  the  peritoneum  and  e.xter- 
nal  muscular  coat  of  the  appendi.v  cireumeised. 


500 


INTESTINAL   COMPLICATIONS. 


care  not  to  let  any  of  it  run  onto  the  peritoneum.     The  reflected  peritoneal 
cuff  is  now  drawn  down  over  the  little  stump  and  turned  in  so  as  to  bring  the 

peritoneal  margins  together, 
when  it  is  sutured  from 
side  to  side  with  a  continu- 
ous overlapping  fine  silk 
suture  threaded  in  a  straight 
needle.  The  stump  of  the 
appendix  now  appears  like 
a  little  tit  on  the  cecum,  or 
it  lies  almost  hidden  be- 
tween the  cecal  folds.  The 
end  of  the  appendix  is 
finally  completely  put  out 
of  sight  in  an  extraperito- 
neal pocket  by  a  catgut  su- 
ture catching  it  and  pass- 
ing: throuffh  the  sides  of  the 
little  triangular  opening  at 
the  base  of  the  mesenteri- 
olum ;  upon  tying  the  su- 
ture, the  stump  is  drawn 
down  between  the  layers  of 
the  peritoneum,  which  are 
also  approximated  at  the 
same  time. 

In  some  cases  where 
there  is  extensive  suppura- 
tion of  the  appendix,  or 
where  its  peritoneal  coat  is 
friable,  it  may  not  be  possi- 
ble to  obtain  a  peritoneal 
envelope  for  the  stump.  Where  this  can  not  be  effected  it  is  better  to  throw  a 
silk  ligature  around  the  entire  appendix,  tying  it  tightly,  and  then  to  cut  it  off 
beyond  the  ligature,  sterilizing  the  end  and  covering  it  with  the  peritoneum 
by  suturing  a  fold  of  the  colon  over  it.  This  method  is  satisfactory,  and  is 
advocated  in  all  cases  by  some  surgeons.  It  is  not  necessary  to  cut  oif  the 
appendix  flush  with  the  colon  unless  it  is  diseased  throughout ;  in  some  cases 
the  ulceration  extends  out  into  the  cecum  and  it  may  be  necessary  to  remove 
the  neighboring  part  of  the  bowel  which  should  then  be  closed  with  mattress 
sutures. 

The  pelvic  operation  is  now  completed,  taking  care  not  to  infect  the  perito- 
neum w^th  the  adherent  end  of  the  appendix  wrapped  in  gauze. 

Suture  of  the  Intestines.— Intestinal  suture  is  re(|uired  (1)  when  any  part  of 
the  muscular  coats  of  the  bowel  has  been  torn  in  separating  adhesions,  (2)  when 


Fio.  5G0.— Third  Step  in  the  Operation  for  Appendicitis. 

The  cuff  of  peritoneum  and  external  muscular  coat  turned  up 
onto  the  cecum  and  a  fine  silk  lisature  applied  to  the  stripped  ap- 
pendix, eonsistinj,'  now  only  of  circular  muscular  tillers  and  mu- 
cosa. The  lijrature  must  fje  applied  as  close  as  possible  to  the 
cecum.  Tlie  appendix  is  then  amputated  just  beyond  the  ligature, 
and  the  little  area  of  exposed  mucosa  distal  to  it  sterilized  with 
pure  carbolic  acid. 


SUTUKE   OF   THE    IXTESTIKES. 


501 


tlie  lumen  of  the  bowel  is  opened,  (3)  when  there  is  a  stricture  of  the  bowel 
which  endangers  life,  or  (4)  when  there  is  an  mtestinal  fistula. 

l^eedle  and  Sutures . — The  best  needles  for  the  intestinal  suture  are 
either  a  long,  slender  one  ^vith  a  round  point  and  without  cutting  edges,  called 
a  straw  needle,  size  No.  8,  and  milliners'  needles,  sizes  No.  9  or  No.  10,  which 
are  longer  than  the  ordinary  cambric  needles,  or  a  little  round  curved  French 
needle  with  an  eye  opening  with  a  little  spring  at  the  end. 

In  suturing  the  rectum  where  the  coat  of  the  bowel  is  thick,  a  small,  curved, 
flat  needle  with  a  carrier,  and  held  in  a  needle  holder,  may  be  used  with 
advantage. 

The  finest  silk  thread  is  used — black,  iron-dyed,  or  white.  Each  thread  is 
about  30  centimeters  long  and  threaded  directly  through  the  eye  of  the  needle. 
If  the  straight  needles  are  used,  it  is  best  to  have  about  thirty  of  them  threaded 
ready  for  any  operation  and  preserved  rolled  up  in  a  towel  (see  Fig.  565).  The 
threads  do  not  get  tangled  if  they  are  drawn  through  the  towel  a  few  times  in 
parallel  rows.    The  needles  are  stuck  in  in  a  row,  as  practiced  by  Dr.  W.  S.  Halsted. 

The  sterilization  of  the  sutures  is  effected  by  rolling  them  up  in  the  towel, 
pinning  another  towel  about  them,  and  placing  them  in  the  steam  sterilizer. 
After  sterilization  they  are  dried  out  thoroughly  and  put  away.  This  plan  of 
keeping  them  dry  is  better  than  the  practice  of  immersing  them  in  alcohol  or  in 
juniper  oil. 

The  Fibrous  Coat  of  the  Intestine . — T  he  most  valuable 
contribution  which  has  as  yet  been  made  to  intestinal  sur- 
gery is  the  demonstration  by  Dr.  W .  S .  Halsted  of  the 
fact  that  the  essential  feature  in  any  suturing  or  anas- 
tomotic operation  is  the  employment  of  the  submucous 
intestinal  coat.  This  is  an  exceedingly  tough  fibrous  membrane,  air- 
tight and  water-tight ;  it  is  the 
"  skin "  in  which  sausage  meat  is 
stuffed.  It  is,  moreover,  the  coat 
of  the  intestine  from  which  "  cat- 
gut" is  made. 

Halsted  has  shown  (see  Cir- 
cular Suture  of  the  Intestine : 
An  Experimental  Study,  Am. 
Jour,  of  the  Med.  Sci.,  Oct., 
1887;  see  also  Intestinal  Anas- 
tomosis, Johns  Hopkins  Hosp. 
Bull,  No.  10,  Jan.,  1891)  that 
the  taking  up  of  the  serous  or  of 
the  serous  and  the  muscular  coats 
in  the  suture  is  insufficient  to 
assure  the  permanency  of  the  hold,  but,  on  the  other  hand,  "a  delicate  thread  of 
this  tissue  (the  submucous  coat)  is  very  much  stronger  and  better  able  to  hold 
a  stitch  than  is  a  coarse  slired  of  the  entire  thickness  of  the  umscular  and  serous 


Fio.  5G1. — .\fter  Amputation  and  Sterilization  the 
Stump  is  allowed  to  Retract  (seek  in  Faint  Out- 
line) WITHIN  the  Cuff  of  Peritoneum. 


502 


INTESTINAL    COMPLICATIONS. 


Fig.  502. 


-CluSLUE    uF    the    rEKITONEAL    CUFF    OVEK    THE  StUAIP  BY 

Mattress  and  Interrupted  Sutures. 


Partial  closure  of  tlic  meseiiteriolum,  using  interrupted  or  mattress 
sutures. 


coats."     In  fifteen  experiments,  including  eighteen  circular  sutures  of  the  intes- 
tine made  by  Halsted,  all  succeeded. 

The  importance  of  this  discovery  has  been  demonstrated  by  the  experiments 
of  AV.  Ednmnds  and  Charles  A.  Ballance  in  the  Brown  Institution  (see  Ohs.  and 

Exper.  on  Intestinal  and 
Gastro-intestinal  Anasto- 
mosis^ Medico-chirurgical 
Transactions^  vol.  Ixxix, 
London,  189fi).  I  have 
made  some  measurements 
similar  to  those  of  Ed- 
munds and  Ballance,  and 
present  the  figures  in  the 
text  in  order  to  show  the 
position  and  relative  thick- 
ness of  this  fibrous  layer 
in  the  small  and  in  the 
large  intestines.  It  is  evi- 
dent from  the  figures  that 
it  is  relatively  quite  a  stout 
tissue,  especially  in  the 
rectum,  where  it  attains 
its  maximum  development. 
The  practical  question  is  how  this  fibrous  layer  can  be  recognized  in  passing  the 
sutures.  This  is  done  by  pushing  the  needle  vertically  through  the  wall  of  the 
intestine  after  transfixing  the  serous  and  mucous  coats.  On  reaching  the  fibrous 
layer  it  at  once  meets  with  a  considerable  resistance,  which  becomes  still  greater 
if  the  needle  is  passed  horizontally  through  its  meshes.  It  is  not  difficult  with 
experience  to  turn  the  sliarp 
point  so  as  to  pick  up  a  shred 
of  this  fibrous  layer  each  time 
without  ever  entering  the  lu- 
men of  the  bowel. 

Simple  interrupted,  mat- 
tress, and  continuous  sutures 
may  be  used.  The  simple  in- 
terrupted suture  should  only 
be  used  in  the  rectum  or  for 
a  short  clean  cut  in  the  small 
bowel.  The  continuous  rec- 
tangular suture  may  Ije  applied 
occasionally  to  longer  straight 

+par-  Tlio     ■mot+i'occ     on+nTO    lo  ^"''  ^^'''^' — INVERSION  AN1>    E-XTKAPEKITONEAL    DISPOSAL  OK  THE 

ledrss.       J  lie   mattress   suture  is  Little     Blttonlike    Sti  MP    BENEATH    THE    Contiguous 

the  securest  of  all  and  is  always  Margins  of  the  Mesenteriolum. 

ncorl  ITT  QTioo-f/^      r    ■  This  IS  accomplished  by  passing  a  suture,  as  shown,  and 

USeU  in  anastomohing.  tying  it,  in  this  way  turning  the  stump  in. 


SUTURE    OF   THE    INTESTIXES. 


503 


Fig.  504. — Curved  Ixtestixal 
Needle,  Ordinary  Size. 
The  eye  is  split  open  at  the 
end  and  barbed,  as  shown,  for 
the  insertion  of  tlie  thread. 


/-M 


l.\      I       I       I      I 

U  1  LIT] 


h 


The  mattress  and  the  continuous  sutures  enter  and  emerge  on  the  serous  sur- 
faces, and  so  serve  to  turn  in  the  edges  of  the  boweL     Care  must  be  taken  not 
to  roll  in  too  much  of  an  edge  in  this  way  in  order  to 
avoid  a  large  tlange  projecting  into  the  lumen. 

Cleanliness . — When  the  lumen  of  the  bowel 
is  opened  the  operator  must  immediately  try  to  avoid 
the  escape  of  any  of  its  contents  onto  the  peritoneum. 
This  will  be  done  by  bringing  the  bowel  outside  the 
incision  whenever  it  is  jDOSsible,  and  laying  it  upon 
gauze  pads  while  the  oj)ening  is  being  closed. 

r,r~^-^,-^r~^r-^t-^^~>r-i-^^  If  tlic  iujury  is  extensive  and  the  operation  is  to  be 

i.  ,1  I  I  I  I  /f^  a  long  one,  as  in  an  anastomosis,  it  will  be  best  to  shut 
ofi  any  communication  with  the  upper  and  lower  bowel 
by  passing  a  piece  of  rubber  tubing  through  the  mesen- 
tery at  a  convenient  distance  above  and  below  the  field 
of  operation  and  fastening  it  with  a  single  tie,  or  a  piece 
of  wood  shaped  like  a  toothpick  may  be  thrust  through 
the  mesentery  and  a  rubber  band  stretched  across  the 
bowel.  The  bowel  should  then  be  irrigated  with  salt 
solution  and  its  mucous  surfaces  cleansed  with  peroxide 
of  hydrogen. 

As  soon  as  the  discovery  is  made  that  a  part  of  the 
bowel  is  injured  which  can  not  be  lifted  out  in  this  way, 
it  will  be  best  to  surround  it  at  once  on  all  sides  with 
gauze  pads  to  protect  the  peritoneum  while  the  injury 
is  being  repaired. 

Tear  of  the  Peritoneal  and  Muscular 
Coats, — A  tear  of  the  muscular  coat  always  calls  for 
suture.  A  simple '  continuous  suture  of  catgut  or  of 
fine  silk  may  be  used,  taking  in  the  peritoneum  and 
the  torn  muscularis ;  this  should  be  applied  in  such  a 
way  as  both  to  restore  the  muscle  to  its  position  and  to 
avoid  narrowing  the  lumen  of  the  bowel. 

When  the  Lumen  of  the  Bowel  is 
O  p  en  e  d  . — If  the  bowel  is  opened  by  a  cut  or  a  small 
hole  this  may  be  closed  either  by  interrupted,  mattress, 
or  a  continuous  rectangular  suture,  entering  but  not 
perforating  the  fibrous  layer;  the  mattress  and  inter- 
rupted sutures  ought  to  be  placed  close  together,  at  in- 
tervals not  greater  than  1  or  2  millimeters.  A  little 
hole  in  the  bowel  may  be  closed  snugly  by  a  rectangu- 
lar or  a  purse-string  suture. 

AVhen  the  Rectum  is  Injured. — When 
the  rectum  is  torn  open  the  ditficulties  of  getting  at 
the  field  of  operation  are  nmcli  greater  than  elsewhere, 


'-/■  \yy^<!¥if/\v/o 


r  f 


"(^  'i<y/-'\ 


\W 


? 


Fig.  505. — IIai.sted'h  Mktiioh 
of  prkskrving  tiik  ixtks- 
TiNAL  Nkedles,  TiIUEADKI) 
AND  Sterilized,  m  a  Tow- 
el, y^  Actual  Size. 
75 


504 


INTESTINAL   COMPLICATIONS. 


but,  on  the  other  hand,  the  remarkable  thickness  of  this  part  of  the  bowel  makes 
it  much  easier  to  suture  it  and  to  bring  the  edges  of  the  tear  into  accurate  appo- 
sition. I  prefer  in  this  case  to  use  interrupted  sutures  placed  close  together 
and  passed  with  a  small  curved  needle  and  a  line  silk  carrier.  A  straight  needle 
can  not  be  used  with  advantage,  because  there  is  not  room  enough  deep  down 
in  the  pelvis  to  push  it  in  and  draw  it  through.     It  is  most  necessary  in  these 

cases  not  to  constrict  the  lumen  of  the 
bowel,  as  the  suturing  will  not  stand 
the  pressure  of  formed  fecal  matter 
accumulating  on  the  proximal  side  of 
the  stricture. 

In  these  rectal  cases  the  tear  is 
most  apt  to  occur  during  the  enuclea- 
tion of  inflammatory  masses  from  the 
pelvis,  and  in   that   event   the   bowel 


MM  wM  rnmi 

tf."ii-'t;'  A-'K  mi  '/•  'i.M  lii'-*  V'^ 


£^^^'i^:^!^ijV^4l,'^j^^'l^j'ij^^^ 


j.lm 
P 


«-3<ro>.-T-. 


Fio.  56';. — Human  Small  Intestine  maonified  One 
Hundred  Times  to  show  the  Relative  Thick- 
ness OF  the  Vakious  Coats. 
/>,  the  peritoneum ;  ??»,  the  longitudinal  and  cm 

the  circular  muscular  coats;  H  is   the  flljrous  coat, 

and  mm  the  museularis  mucosa; ;  ij  marks  the  glands, 

and  V  the  long  villi. 


Fig.  567. — A  Section  of  the  Colon  magni- 
fied One  Hundeed  Times. 
Showing  fiS')  the  fibrous  coat  about  us  thick 
as  the  circular  muscular  coat  and  of  about  the 
same  thickness  as  in  the  small  intestine.     The 
letters  are  the  same  as  in  the  last  figure. 


may  ]>e  torn  into  or  torn  across  flush  with  the  hardened  infiltrated  pelvic  floor. 
It  is  not  possible  to  suture  together  the  torn  surfaces  under  these  conditions, 
and  the  first  step  taken  must  be  to  dissect  out  and  set  free  enough  of  the  lower 
part  of  the  bowel  to  secure  good  tissue  which  can  be  joined  to  the  upper  end 
without  traction. 


LATERAL   ANASTOMOSIS. 


505 


In  rectal  tears  opening  tlie  lumen  of  the  bowel,  except  in  well-closed  small 
wounds  with  healthy  surrounding  tissues,  it  is  always  safer  to  make  a 
free  opening  in  the  vaginal 
vault  posterior  to  the  cervix, 
and  to  put  in  a  washed-out 
io  do  form  gauze  drain  for  sev- 
eral   days   or   a   week. 

In  one  instance  (J.  S.,  357,  Sept.  2, 
1890)  in  which  the  muscular  coats  of  the 
rectum  were  torn  through  in  a  triangu- 
lar shape  from  the  pelvic  floor  to  the 
brim,  with  the  base  of  the  tear  at  the 
floor,  I  covered  in  the  large  denuded 
area  by  suturing  the  uterus,  in  retrojjosi- 
tion,  to  the  bowel  on  each  side  with  a 
continuous  suture  {Johns  Ilopk.  Hasp. 
Bep.,  vol.  iii,  1894,  p.  413). 

In  another  case  (M.  P.,  5014,  Feb.  13, 
1897)  the  rectum  was  torn  completely 
across  at  the  pelvic  floor,  the  end  being 
held  together  only  by  the  mesenteric 
border.  There  was  no  discharge  or  odor 
from  the  bowel,  which  was  scarcely  de- 
tected amid  the  mass  of  pelvic  adhesions. 
The  torn  surfaces  were  repaired  in  the 
following  way  :  The  lower  end  of  the 
rectum  was  dissected  out  and  freed  from 
the  bed  of  adhesions  on  the  pelvic  floor, 
and  tlien  united  to  the  upper  end  by  a 
series  of  thirty  interrupted  flne  silk  su- 
tures passed  with  a  small  curved  needle 
and  a  carrier,  beginning  at  the  floor  of  the  pelvis  at  the  left  side  and  extending 
ol:»liquely  upward  on  the  right  side  to  the  level  of  the  second  sacral  vertebra. 
Each  suture  penetrated  the  coats  of  the  bowel  down  to  the  mucosa,  and  the  dis- 
tance between  them  was  about  2  millimeters.  A  small  gauze  drain  was  j)assed 
through  the  vaginal  vault.     Perfect  recovery  ensued,  without  flstula. 

Lateral  Anastomosis. — If  the  bowel  is  gangrenous,  or  is  strictured  to  such 
an  extent  as  to  threaten  the  life  or  the  health  of  the  patient,  it  will  be  neces- 
sary to  establish  a  comnmnication  between  the  sound  lumen  above  and  below, 
in  this  way  anastomosing  the  bowel  to  itself  and  bridging  over  the  diseased 
area. 

A  simple  and  nuich  practiced  form  of  anastomosis  is  by  the  approximation 
of  the  lateral  surfaces  with  an  opening  between  them,  and  tlie  best  plan  of 
operation  is  Ilalsted's,  which  T  shall  closely  follow  throughout  in  my  description 
(see  Figs.  509  to  573). 


■^'■$:pi'^ 


Fig.  568. — Compare  this  Drawing  of  the  Coats 
OF  THE  Rectum  seen  in  Cross-section  and 
only   magnified  Twentv-five   Times,  with 

THE      preceding      PICTURES      MAGNIFIED      OnK 

Hundred  Times. 

The  lil)rous  coat  (mi)  is  almost  four  times,  the 
circuhiris  about  eijrht  times,  aud  the  lon^itudiiialis 
about  sixteen  times,  as  thick  as  in  the  bowel  liigh- 
er  up.     Spec.  1024. 


506 


INTESTINAL    COMl'LTCATIOXS. 


First   the  upper  piece  of  bowel    is   brought  down    beside   the   lower,  and 
from  six  to  eight  mattress  sutures  apphed  on  the  side  toward   the  mesentery, 


Hill    h  I J  r 


1 


Fig.  SG'.t. — Lateral  Anastomosis. 
The  ends  of  the  bowel  closed,  and  mattress  sutures  introduced  on  the  lower  side. 


and  drawn  up  and  tied,  as  shown  in  the  figures.  Two  lateral  sutures  are 
then  applied  at  either  end,  so  as  to  curve  the  line  of  approximation  forward  ; 
these  are  now  tied,  and  an  anterior  row  of  sutures  is  next  laid,  completing  an 

oval  figure,  as  shown,    Be- 
'""  "       fore  tying  these  they  are 

drawn  apart  in  order  to 
cut  generous  openings  into 
the  bowel  on  both  sides, 
so  as  to  effect  the  anasto- 
mosis ;  the  openings  nmst 
])e  large  enough  to  allow 
for  the  subsequent  contrac- 
tion. As  soon  as  this  is 
^gjfljL  \    i  done   all    the    sutures   are 

^^^F  [     fv^nHK         tied   and   the  operation  is 

jff^^  'I      "■"'■'''■'^         completed.     The  duration 

of  this  operation  in  skilled 
hands  is  from  eight  to  ten 


Fio.  570. — LowEK  Row  of  Stti-res  tied  and  tiik  I^atekal  Sutures 
APPLIED,  Two  at  Each  P^nd. 


minutes. 


END-TO-EXD    AXASTOMOSIS. 


507 


End-to-end  Anastomosis. — In  end-to-end  anastomosis  after  Halsted's  method 
(see  Circular  future  of  the  InteKtlne^Amer.  Jour,  of  the  Med.  Set..  Oct.,  1887), 
the  mattress  sutures  are  used  to  bring  the  opposed  edges  into  accurate  apposi- 
tion on  all  sides.     The  bowel  must  present  an  even  edge  and  must  not  project 


FiQ.  571. — The  Latekal  Sutuhes  tied  also,  makixg  a  Pocket. 

beyond  its  mesentery  upon  which  it  depends  for  nutrition.  The  sutures  are  laid 
about  :2  millimeters  apart,  as  nearly  as  possible  in  a  straight  line  around  the 
bowel,  and  all  of  them  are  put  in  place  before  a  single  one  is  tied  ;  each  suture 
is  made  to  penetrate  but  not  to  perforate  the  fibrous  layer  of  the  gut  close  to  its 


Fio.  572. —  Ke.mainixu  Sutikes  in  1'lale  keady  to  comi'i.kte  the  L'mon  on  all  Sides. 

The  bowel  is  now  freely  opened  between  the  upper  iiiul  lower  layer  ot'  sutures,  estsiblishlng  the  anasto- 
mosis in  the  direotion  of  the  arrows. 


nuirgin,  in  order  to  avoid  turning  in  a  broad  fiange  toward  the  lumen  of  the 
bowel  to  act  as  an  obstruction  (see  Figs.  574  to  577).     On  account  of  the  diffi- 


508 


INTESTINAL   COMPLICATIONS. 


culty  of  accurate  approximation  at  the  mesenteric  border  a  painstaking  attention 
must  be  given  to  each  stitch  as  it  is  laid  ;  the  union  at  this  point  will  be  further 


Fig.  573. — Lateral  Anastomosis  completed,  all  thk  Sutlkks  tied. 
Tlic  fecal  current  now  freely  follows  tlie  course  indicated  by  the  arrows. 

facilitated  by  selecting  a  spot  for  the  resection  which  is  free  from  fat  and  large 
vessels.  A  good  resection  is  characterized  by  good  union  on  all  sides,  and  fur- 
ther by  the  absence  of  post-operative  adhesions  about  it. 


nil 


Fig.  574. — End-to-End  Anastomosis  without  Aktificial  Aids. 
Presection  sutures  in  place  and  about  to  be  tied. 


CIRCULAR   SUTURE   OF   THE    INTESTINE. 


509 


The  sutures  are  tied  and  the  slit  in  the  mesentery  closed,  taking  care  not  to 
interfere  with  its  circulation,  and  the  operation  is  completed.     If  the  row  of 


Fig.  575. — Pkesection 
Sutures -TIED. 


V  \  Wflil   M/. 


Fig.  576. — Mattress  Sdtukes  ix  Flace. 


circular  sutures  has  been  well  applied  there  is  no  need  of  a  second  row  to 
reinforce  them. 

Circular  Suture  of  the  Intestine  with  the  Use  of  Inflated  Rubber  Cylinders. — 
Owing  to  the  flacciditj  of  the  bowel,  its  tendency  to  contract  at  the  cut  edges, 
and  a  possible  difference  in  the  lumina  of  the  two  ends  to  be  brought  together, 
the  process  of  adjustment  of  the  resected  ends  just  described  may  sometimes 
present  considerable  difficulties,  interfering  with  the  accuracy  of  the  apposition, 
and  therefore  introducing  an  element  of  uncertainty.  All  these  difficulties  have 
been  obviated  by  the  invention  of  an  mflatable  rubber  cylinder  which  is  intro- 
duced into  the  bowel,  as  shown  in  the  inset  cut ;  upon  this  the  ends  are  easily 
and  accurately  Ijrought  together,  and  just  be- 
fore the  last  stitches  are  tied,  the  air  is  let 
out  and  the  cylinder  withdrawn  (see  Halsted 
in  the  FhUa.  Jled.  Jour.,  Jan.  8,  1898).  This 
method  of  suture  is  so  simple  and  so  satisfac- 
tory that,  before  operating  upon  human  beings, 
every  surgeon  should  familiarize  himself  with 
it  by  repeatedly  practicing  upon  dogs  until  a 
series  of  successful  results  are  obtained  (see 
Figs.  578  to  585). 

The  method  of  using  the  cylinder  is  as 
follows :  In  the  first  place,  before  resecting 
the  intestine,  its  blood  supply  should  be  care- 
fully studied   Mith   reference   not  only  to  the 

placing  of  the  ligatures  luit  also  of  the  stitches,  and  each  stitch  should  be  so 
placed  that  the  circulation,  up  to  the  very  edge  of  the  cut,  should  be  interfered 
with  as  little  as  possible. 

The  intestine  is  first  caught  by  the  presection  sutures  (see  Figs.  578  and  579), 
and  it  is  innriaterial  whether  they  enter  the  lumen  of  the  bowej  or  not,  as  they 


w 


(^ 


Fio.    577. — Sitli:ks    ai.i     i       •.   - 
Accurate   Ai'i'RO.\iJiAiiu.N    ot 
Divided  Ends  of  the  Bowel. 


510 


INTESTINAL    COMPLICATIONS. 


are  finally  cast  off  into  the  bowel.  The  figures  show  also  the  method  of  ligat- 
ing  the  mesenteric  vessels  taken  from  life. 

The  intestine  slujuld  then  he  divided  with  scissors  as  close  to  the  presection 
sutures  as  possil)le  ;  two  of  the  sutures  are  then  tied,  and  the  collapsed  rubber 
cylinder  pushed  into  the  bowel  with  forceps,  so  that  one  half  lies  in  each  end 
and  the  inflation  tube  conies  out  in  the  middle. 

In  Fitr.  581  the  three  j^resection  sutures  are  shown  tied,  and  a  supplementary 
fourth  stitch  (h)  is  introduced  ;  this  is  cut  later  to  facilitate  the  withdrawal  of 
the  l)ag. 

The  bag  is  now  inflated  with  air  until  the  intestine  is  distended  to  its  normal 
caliber. 

The  mesenteric  stitch  {a)  (see  Figs.  581  to  584)  is  the  first  and  most  important 
of  the  mattress  or  permanent  sutures ;  by  it  the  subnmcosa  is  picked  up  four 
times  (as  indeed  by  all  the  mattress  stitches),  and  the  mesentery  is  perforated 
twice ;  by  placing  the  stitch  as  shown  hi  the  figures  the  mesenteric  border  is 


m 


;Jl^ 


I/O 


Flli.    67». ClKCULAK    SUTUKE    OK    THE    iNTESTI.Nh. 

Sliowiiij^  tlic  lir.st  step  iii  the  introduction  of  the  presection  sutures,  six  in  number.  These  serve,  wlieu 
the  bowel  is  resected,  to  baste  the  ends  tojsrether,  as  it  were,  facilitating  the  subsequent  ai)j)lication  of  the  mat- 
tress sutures  which  secure  accurate  union  tliroughout.  The  area  to  Be  excised  is  included  within  the  dotted 
lines;  this  must  always  be  carefully  selected  with  reference  to  the  arranrjement  of  the  blood  vessels,  so  as  to 
secure  vessels  going  to  the  cut  edges,  and  at  the  same  time  to  avoid  including  any  vessels  in  the  subsequent 
suturing,  as  shown  in  the  figure.     ISote  the  ligatures  applied  to  vessels  before  dividing  the  intestine. 


^s^"^ 


Fig.  5m». — The   Ixthoductiox  of  the  Collapsel    Kiiiber  Cylinder  between  the  Presection  Sutures. 


'\     .   J^ 


Fio.  581. — After  tying  the   Three   1'ke!^ection   Sutures  and   inserting   the   Kubber  Bag   a   Fourth 

Stitch,  b,  is  inserted. 

The  cylinder  inflated  and  a  fourtli  suture  inserted  near  the  tube. 


EXD-TO-SIDE    AXASTOMOSIS. 


511 


turned  in,  and  the  bowel  is  brought  snugly  and  evenly  together  at  the  very  point 
which  is  apt  to  be  the  weakest  in  the  series. 

From  ten  to  twelve  mattress  sutures  are  now  placed  around  the  intestine, 
from  mesenteric  border  to   mesenteric         ^  border,    taking    care   not  t» 


occlude  a  single  vessel   by  pass- 
the  case  may  be.      All  of  the 


ing  under  or  over  them,  as 
sutures     except     the     mes- 
enteric are  passed  before  ty- 
ing   them,    and    if    any    suture 
takes   up   more   than   the   snbmu- 
cosa  and  enters  the  bowel  and  pricks 
the    cylinder,    this    is    at    once    known 
j^f  \  ^Bfi^j^      /y^     ^^^  *^®   escape    of   the  air,  and  the   suture 

^  ^  ^Sk£JLj^\  //  must   be   taken   out   and   a  fresh    cylinder 

put  in. 

After  the  sutures  are  passed  and  the 
bag  is  withdrawn,  they  are  tied  and  cut  off 
short  and  the  bowel  snugly  united  on  all 
sides. 

The  use  of  the  inflated  rubber  cylinder 
not  only  prevents  the  escape  of  the  bowel 
contents,  but  it  also  preserves  the  intes- 
tine from  the  constriction  of  a  clamp  and 
from  handling  by  an  assistant.  Perhaps  the 
greatest  advantage  of  the  method,  however, 
is  the  easy  adaj^tation  secured  in  lumuia 
of  various  sizes,  which  must  be  brought 
together. 

End-to-side  Anastomosis  —  S  i  g  m  o  i  d  o  - 
p  r  o  c  t  o  s  t  o  m  y  . —  I    have  had  but 
one  case  in  which  an  anastomosis  of  the  upper  end  of  the  bowel   into 
the   side   of   the   lower  end  was  necessary  (see  Johns.   Ilojjk.  IIoxp. 
BnU.,  Feb.,  1895).     The    patient  (B.  W.  M., 
1161)   had   a    long    tubular    stricture   of    the 
rectum  extending  from  the  ampulla  u})  to  the 
sigmoid  flexure,  and  in  operating  for  a  pelvic 
inflammation    with    dense   adhesions   the   con- 
tracted bowel   was  mistaken  by  her  physician 
for  a  uterine   tube   and  cut   off ;   the  ends  of 
the  l)owel  were  brought  out  at  the  abdominal 
incision,   and  she  recovered    with   an    artiflcial  _^ 

anus.  Fu;.    :>^-l.      rm.    Mi..-i.mi.i;u     Mattkess 

Ai         X    ^  ^^        ^    J.  /^    J.      o,>     -loni     T  SirriiK    dkviskd    by    MmiiEi.L   and 

About  two   months   later,  Oct.   20,  1SD4,  1  Hin.nek. 

extirpated,  by  a  most  diflicult   dissection,    the         Showing' how  it  is  passed  to seouro  ac- 

'  '       "  _  _  ^  '  curate  aiUKisitioii  (it  tiK' howfl  on  tlie  side 

uterus,  tubes,  and  ovaries  buried  in  a  mass  of     wiiere  the  union  is  nidst  diitiiuit to  ob- 

,,       .  ,  .  •  II  n  Xmw.     Each  time  the  suturo  is  introduceti 

adhesions;   as  the  patient  was  rapidly  coJlaps-     ittakes  up  u  bitofthesubmucosu. 


Fig.  579. — Oxe  of  the  Divided  Ends  of 
THE  Intestine. 

W^ith  its  presection  sutures  ready  to  be 
drawn  over  and  rouglily  approximated  to  the 
opposed  end.  Both  sets  of  presection  sutures 
are  applied  in  exactly  corresponding  posi- 
tions, and,  owing  to  the  fact  that  they  are 
turned  in  by  the  next  set  of  sutures,  it  niakes 
uo  ditference  even  if  they  penetrate  all  the 
coats  of  the  bowel;  note  the  position  of  the 
two  ligated  vessels  on  the  very  edge  of  the 
mesentery. 


512 


INTESTINAL    COMPLICATIONS. 


ing,  I  completed  the  operation  hastily  by  closing  the  distal  end  of  the  stricture, 
incising  the  ampulla,  and  pulling  the  sigmoid  end  of  the  bowel  down  into  the 
incision,  which  it  fitted  snugly,  and  holding  it  there  by  traction  sutures  brought 
out  at  the  anus  in  the  grasp  of  forceps. 


■vXv 


X  •  :^^ 


Fig.  583. — Fkom  Tkn  to  Twelve  Mattress  Sutures  are  introduceu,  as  siiuwn,  and  the  tying  uegun 

WITH  THE  Mesenteric  Suture  a. 

Great  care  is  taken  not  to  include  any  of  the  vessels  in  a  suture,  as  is  shown  by  piissinj,'  the  needle  under 
one  vessel  and  over  another. 


One  essential  feature  was  wanting  to  the  permanent  success  of  the  operation, 
and  that  was  the  suture  of  the  peritoneal  surfaces  of  the  entering  and  receiving 
bowel.  With  the  rough-and-ready  plan  of  treatment  adopted  the  patient  lived 
for  three  months  and  had  normal  bowel  movements.     The  autopsy  showed  that 


ILEO-CECAL    ANASTOMOSIS. 


513 


the  upper  part  of  the  bowel  had  retracted,  leaving  a  cavity  lined  bj  mucous 
membrane  between  it  and  the  ampulla. 

Ileo-cecal  Anastomosis. — A  case  of  fibroid  tumor  of  the  ovary  (M.  F.,  2237^, 
Oct.  7,  1893)  was  complicated  by  tiglit  strictures  of  the  ileum,  causing  perito- 
nitis and  the  ejection  of  matter  from  the  mouth  having  a  fecal  odor.  On 
opening  the  abdomen  two  strictures  were  found  in  the  ileum,  one  IS  centi- 
meters above  the  ileo-cecal  valve,  and  the  other  12  centimeters  above  this — 


Fig.  584.— Now  that  the   Sutikks  ake  all  intkouuced,  Two  of  them   ake   t^Ki'AKATKK  to  allow  the 

Deflated  Bag  to  be  withdrawn. 


that  is,  30  centimeters  distant.  The  gut  between  the  valve  and  the  fin^^t  stricture 
was  flat  and  contracted  down  to  1'5  centimeter  in  diameter. 

The  portion  between  the  strictures  was  distended  with  fluid,  and  was  spindle- 
shaped,  deeply  injected,  its  surface  covered  with  a  light  grayish  lymph. 

i]ach  of  the  strictures  appeared  as  a  little  spherical  nodule  1  centimeter  in 
diameter,  to  which  the  lumen  of  the  bowel  suddenly  contracted.  In  the  angle 
between  the  nodules  and  the  bowel  a  little  pus  had  accumulated,  and  from  the 
lower  nodule  a  thick  mass  extended  up  the  mesentery  2  to  3  by  (>  centimeter.s. 


514: 


INTESTINAL   COMPLICATIONS. 


The  extreme  dense  contraction  made  any  attempt  to  establish  even  a  small 
lumen  through  the  strictures  hopeless,  so  an  anastomosis  was  made  between  the 
distended  ileum  above  the  strictures  and  the  cecum,  turning  the  strictured  part 
of  the  bowel  up  and  flexing  it  on  itself  so  as  to  bring  them  together.  The 
bowels  moved  naturally  and  there  was  no  leakage,  and  a  complete  recovery  fol- 
lowed. In  this  way  the  portions  above  and  below  the  strictures  came  into  ap- 
proximation most  easily  ;  the  ileum  and  the  colon  could  not  be  so  easily  drawn 
together  on  account  of  the  rigid  strictured  portion  between,  which  would  not 
bend  easily  in  the  opposite  direction. 

The  anastomosis  was  eifected  by  bringing  the  bowel  outside  and  laying  it  on 
pads  of  gauze.  A  continuous  rectangular  silk  suture,  5  centimeters  long,  was 
then  passed,  uniting  the  ileum  to'  the  head  of  the  cecum  below  the  line  of  in- 
tended anastomosis,  and  including  all  the  layers  of  the  bowel  down  to  the  mucous 
coat.  Immediately  above  this  a  series  of  mattress  sutures  were  applied  and  con- 
tinued all  the  way  around  the  line  of  intended  anastomosis.     Then  the  sutures 


Fig.  585. — The   Situkes   are  then  all  sxuglt  tied,  and 
THE  Anastomosis  completed. 
The  final  step  is  the  union  of  the  opening  iu  the  mes- 
entery by  a  continuous  suture,  as  shown. 


underneath  were  drawn  up  and  tied,  bringing  serous  surface  snugly  against 
serous  surface.  The  sutures  on  top,  still  united,  were  now  drawn  apart,  and 
the  ileum  and  cecum  cut  open  from  end  to  end  between  for  a  distance  of  about 


ILEO-CECAL    AXASTOMOSIS. 


515 


4  centimeters.  Tlie  ileum,  wliich  contained  a  large  quantity  of  fluid,  was 
clamped  with  the  Angers,  while  the  cecum,  containing  only  gas,  collapsed. 
Pinallj,  on  tying  the  top  sutures,  the  anastomosis  was  effected. 


Fig.  586. — Anastomosis  of  the  Sigmoid   into  the  Ampulla  of  the  Eectum,  after  removal  of  the 
Upper  Paut  of  the  Rectum,  with  the  Uterus,  Tubes,  and  Ovaries. 

The  sigmoid  should  be  attached  to  the  rectuui  by  sero-serous  sutures. 


The  original  continuous  suture  was  now  carried  all  the  way  around  so  as  to 
include  the  inner  line  of  mattress  sutures  on  all  sides.  A  gauze  drain  was  put 
in  for  a  few  days  on  account  of  the  existing  peritonitis. 

Anastomosis  Buttons . — The  best  of  all  mechanical  devices  for  a 
rapid  and  accurate  anastomosis  of  the  bowel  is  the  well-known  anastomosis  but- 
ton of  Dr.  J.  B.  Murphy,  of  Chicago. 

My  own  preference  is  alwa^^s  for  suturing,  which  yields  the  best  results  in 
good  hands.  The  objections  nrged  against  the  suture,  as  contrasted  with  me- 
chanical devices,  are  that  it  takes  a  long  time  to  put  the  sutures  in  and  get  them 
tied,  and  that  the  approximation  by  suture  is  often  inaccurate.  All  of  these 
objections  are  disposed  of  if  the  operator  will  take  sufficient  pains  to  practice 
first  upon  tlie  cadaver  and  then  u]ion  dogs  to  test  the  effectiveness  of  his  work  ; 
furthermore,  the  chief  sources  of  discrepancy  in  the  results  of  suture  methods 
disappear  if  Ilalsted's  fibrous  layer  is  borne  in  mind  and  if  the  sutures  are 


516 


IXTESTIXAL    COMPLICATIOXS. 


applied  closely  enough.  AVitli  practice  al.-^o  the  time  consumed  in  suturing 
becomes  much  less. 

The  chief  objections  to  the  button  are  that  it  is  a  heavy  piece  of  metal,  that 
it  gives  at  best  but  a  small  anastomotic  hole  liable  to  extreme  contraction,  and 
that  if  not  made  or  selected  with  extreme  care  the  pressure  between  the  opposed 
surfaces  is  sometimes  great  enough  to  cause  sloughing. 

Artificial  Anus  —  Colostomy  . — When  an  ineradicable  malignant 
disease  of  the  uterus  or  of  the  ovaries  chokes  the  pelvis  so  as  to  produce  an 
obliteration  of  the  lumen  of  the  rectum,  it  will  often  be  found  necessary  to  make 
an  artificial  anus  to  prevent  the  j)atient  from  dying  from  simple  obstruction  of 
the  bowels.  By  this  procedure  frightful  pain  may  be  relieved  immediately,  life 
prolonged  many  months,  and  euthanasia  secured. 

The  best  place  to  make  the  opening  is  under  the  left  anterior  superior  iliac 
spine  over  Pou part's  ligament ;  but  if  the  disease  involves  the  upper  part  of  the 
rectum,  it  will  1)e  better  to  do  the  operation  on  the  right  side  and  so  avoid  the 
necessity  of  repeating  it. 


Fio.  587. — Making  a  Sigmoid  Anus  in  Occlusion  of  the  Lower  Bowel. 

The  fif,Mire  show.s  a  vertical  section  through  the  wound  with  two  of  the  sutures  uniting  the  visceral  to  the 
parietal  peritoneum.     K.  ('.     March  23, 1896. 


The  accompanying  illustrations  (Figs.  587  and  588)  show  how  to  operate  : 
A  funnel-shaped  incision  P»  to  8  centimeters  long  is  made  through  skin,  fat,  mus- 
cles, and  peritoneum,  about  3  centimeters  above  and  parallel  to  Poupart's  liga- 
ment, beginning  just  below  the  iliac  spine.  The  sigmoid  is  usually  found  just 
under  the  incision  and  is  sutured  to  the  peritoneum  and  subperitoneal  tissue  by 
interrupted  sutures  of  fine  silk  placed  close  together,  each  one  penetrating  the 
fibrous  layer  of  the  bowel.     The  free  surface  of  the  bowel,  covering  an  oval 


ARTIFICIAL   ANUS. 


51^ 


area  about  2x4  centimeters  should  in  this  way  ])e  made  to  fill  in  the  bottom 
of  the  incision. 

One  of  two  plans  may  now  be  adopted  :  either  the  skin  margins  may  be 
turned  in  and  united  to  the  muscular  layer  and  the  exposed  bowel  opened  its 


)k 

1 

/ 

^g^ 

)i 

hBFjI 

^5^ 

^K   4 

i 

'  / 

t 

■^K^i-  .                                              .  _J 

Fig.  588. — Making  a  Sigmoid  Anus. 

A.  S.  S.,  the  left  anterior  superior  spine  of  tlie  ilium.  In  the  first  picture  the  skin  and  muscles  are  divided 
and  the  bowel  caught  and  attached  on  all  sides  to  the  peritoneum  hy  a  sero-serous  suture.  A  few  silkworm- 
gut  sutures  are  introduced  at  each  end  (at  the  upper  end  in  the  picture)  to  diminisli  the  size  of  the  wound. 
The  bowel  is  then  opened  in  the  dotted  line  and  sutured  to  the  .skin  .surface,  as  sliown  in  the  second  picture. 

full  length  the  next  day  Avitli  the  cautery  knife  after  peritoneal  union  has 
occurred,  or  the  l)owel  may  be  incised  at  once  and  its  mucous  lining  drawn  out 
and  attached  to  the  skin  margin,  which  is  closed  in  at  the  ends,  as  seen  in  tlie 
figure. 

The  subsecjuent  care  is  mainly  that  of  cleanliness. 


7G 


CHAPTER   XXXVII. 

THE   MORE   REMOTE  RESULTS  OF   ABDOMINAL  OPERATIONS. 

1.  Introductory.     IVIoral  questions  involved. 

2.  Scarcity  of  literature  on  remote  results. 

3.  Anatomical  changes  due  to  operation  :    1.  Hernia.     2.  Suppuration.     3.  Fistula?  and  sinuses. 

4.  Enlargement  and  tenderness  of  scar.     5.  Intestinal  adhesions, 

4.  Encysted  peritonitis. 

5.  Local  changes  :  1.  Changes  in  the  vagina.     2.  Changes  in  the  uterus. 

6.  Menstruation. 

7.  Artificial  menopause. 

8.  Insanity. 

The  surgeon  must  ever  bear  in  mind  that  his  relationship  to  his  patient  is 
not  dissolved  with  the  simple  successful  performance  of  an  operation.  His  re- 
sponsibility in  each  individual  case  may  be  summed  up  in  the  following 
manner  : 

1.  He  is  called  upon  to  decide  whether  the  symptoms  the  patient  complains 
of  are  dependent  upon  pelvic  lesions  or  are  merely  coincident  with  them. 

2.  Whether  the  pelvic  ailment  is  sufficient  to  justify  operation. 

3.  Whether  the  remote  sequelae  of  oj^erative  interference  may  not  ])e  even 
more  distressing  to  the  patient  than  the  present  pains. 

I  can  not  dwell  at  length  upon  all  of  these  topics.  The  first  will  be  found 
fully  discussed  by  A.  Hegar  {Die  Zusaramenhang  der  GeschlechtshranJiheiteri 
7nit  nervoesen  Leiden  u.  die  Castration  Jjei  Neurosen^  pp.  83,  Stuttgart,  1885), 
as  well  as  in  a  suggestive  paper  by  Dr.  H.  C.  Coe  {New  York  l^oly clinic^ 
May  15,  1896),  entitled  SyinjdoNiatiG  versus  Anatomical  Cure  after  Gyneco- 
logical Operations. 

One  of  the  reasons  why  it  is  difficult  to  get  at  some  of  the  remote  results  of 
such  an  operation  as  castration,  for  instance,  from  the  moral  standpoint  is  that 
women  are  naturally  reticent  about  matters  of  sex.  Again  it  must  l)e  remem- 
bered that  many  of  these  operations  are  performed  upon  poor  women  and  those 
of  the  lower  classes  who  are  ignorant  and  wholly  unused  to  protesting  against 
injury  of  any  sort,  and  who  accept  life  as  it  comes  (see  Dr.  Sarah  E.  Post,  N. 
Y.  Med.  Jour.,  Sept.  24,  1887). 

In  weighing  the  effects  of  castration  we  dare  not  leave  out  of  sight  the  com- 
mon feeling  that  this  particular  operation  is  a  degradation  to  women,  and  that 
"  the  majority  of  physicians  and  all  laymen  look  upon  w^omen  deprived  of  their 
ovaries  as  unsexed."     (See  Dr.  AVilliam  Goodell,  The  Effect  of  Castration  on- 
Women  and  Other  I'nMeins  in  Gytiecoloyy,  Medical  News,  Dec.  9,  1893.) 

518 


3 1  a  I   end 


"^■■•i^- 


Fig.  589. — Post-operative  Intra-abdominal  Hekma. 

Strangulation  and  frangrene  of  tlie  ileum,  incarcenitod  in  a  band  of  adhesion.  Death. 
The  lower  picture  shows  tlic  size  and  loriii  of  the  constricting  band  after  the  intestine 
was  lifted  out.    Case  of  Dr.  Burj'ess. 


SCARCITY    OF    LITERATURE   ON    REMOTE    RESULTS.  519 

My  own  continued  experience  only  serves  to  confirm  my  opinion  that  the 
castration  of  women  is  often  a  direct  cause  of  domestic  unhappiness,  and  that  it 
has  been  repeatedly  used  by  men  as  a  good  reason  for  breaking  otf  engage- 
ments, and  for  the  violation  of  marriage  vows,  and  the  abandonment  of  wife 
and  children. 

The  husband  of  one  of  my  patients,  a  highly  educated  clergyman,  wrote,  ten 
years  after  the  operation,  in  the  following  terms  upon  the  ethical  side  of  this 
operation  and  its  effects  upon  the  married  life  : 

"  While  ovariotomy  does  not  destroy  sexual  desire  nor  the  pleasure  of  cohab- 
itation, yet  the  removal  of  the  organs  of  motherhood  causes  a  serious  obstacle  to 
the  affections  due  a  wife,  for  in  depriving  a  woman  of  the  possibility  of  children 
there  is  taken  from  the  home  the  unifying  power  of  parental  love  ;  and  no  high- 
souled  affection  can  be  sustained  by  mere  sexual  pleasure  where  the  hope  of 
children  is  taken  away,  and  every  Christian  husband  who  understands  God's 
chief  purpose  in  marriage — namely,  reproduction  of  sj)ecie8— can  not  justify 
marriage  as  merely  the  means  of  sexual  gratification.  As  a  husband  I  believe 
that  neither  lifelong  helplessness  nor  anything  short  of  impending  death  justifies 
ovariotomy,  if  with  the  diseased  organ  or  organs  remaining  there  could  be  the 
remotest  reasonable  hope  of  children.  For  the  woman  pain  of  body  is  prefer- 
able to  the  anguish  of  soul  attendant  upon  the  destruction  of  the  hope  of  becom- 
ing a  mother  ;  and  as  a  man  I  should  in  my  present  light  conscientiously  decline 
to  marry  the  best  of  women  from  whom  had  been  taken  the  sacred  fountain  of 
motherhood.  As  a  priest  I  believe  that  the  absence  of  that  function  excludes 
the  right  of  marriage,  and  if  performed  after  marriage  its  absence  takes  away 
the  right  of  sexual  cohabitation  except  where  that  act  is  needful  to  i3revent  men- 
tal impurity  or  the  sins  of  adultery  or  fornication."  (See  Amer.  Jour,  of  Ohs.^ 
vol.  xxvii,  No.  2,  1S93.) 

Economically,  the  effect  of  castration  upon  thousands  of  women  in  the  prime 
of  life  has  already  been  raised  in  France,  where  the  population  is  decreasing. 

Scarcity  of  Literature  on  Remote  Results . — It  is  surprising 
to  find  in  the  great  body  of  gynecological  literature  so  little  reference  of  any 
sort  to  the  remoter  results  of  the  various  operations,  either  moral  or  physical. 
The  surgeons  wdio  study  their  cases  for  several  years  after  operation  in  order 
to  learn  the  effects  of  extirpation  of  the  pelvic  organs  are  rare. 

One  of  the  first  systematic  investigations  of  this  sort  was  made  by  T.  Spen- 
cer "Wells,  of  London  {Ovarian  and  Uterine  Tumors,  1882),  in  his  tabulation 
of  one  thousand  cases  of  ovariotomy,  Avhere  he  presented  in  a  separate  column  a 
statement  as  to  the  siibsecpient  condition,  showing  that  he  had  conducted  a  cor- 
respondence with  all  of  his  ])atients  with  a  view  to  tracing  their  histories  over  a 
period  of  some  years. 

We  ought  now,  with  a  greater  lapse  of  time  and  an  abundance  of  cases,  to  be 
in  a  position  to  answer  all  important  questions  as  to  the  relationship  between  the 
various  abdominal  diseases  and  the  remote  sequehii  induced  by  the  operative  in- 
vasion of  the  peritoneal  cavity.  An  inquiry  into  the  more  distant  jihysical 
effect  of  the  operation  possesses  far  more  than  a  purely  scientific  value.     It  is  a 


520  THE    MORE    REMOTE    REST'LTS    OF   ABDOMIXAL    OPERATIOITS. 

question  of  the  highest  practical  import  to  each  individual  patient  to  know  in 
what  way  her  future  life  is  liable  to  be  affected  by  any  proposed  surgical  pro- 
cedure. In.  the  first  place  she  will  wish  to  know  what  measure  of  relief  may  be 
expected,  and  in  the  second  how  far  her  physiological  functions  may  be  altered, 
and  whether  the  operation  demands  any  sacrifices,  the  most  conspicuous  of  which 
are  au  incurable  sterility  and  the  loss  of  sexual  function. 

A  decision  as  to  the  permanent  result  can  only  be  recorded  after  studying  a 
long  series  of  cases  for  several  years  after  operation,  for  the  remote  sequelae 
are  often  masked  at  first  by  the  distraction  afforded  by  the  various  temporary 
discomforts  which  form  a  part  of  every  convalescence  ;  moreover,  the  patient 
can  not  justly  estimate  her  new  status  until  she  has  been  restored  to  her  habitual 
surroundinss  under  tlie  new  conditions  for  some  months. 

Such  an  investigation  will  follow  two  lines :  first,  as  to  the  purely  objective 
or  anatomical  changes ;  and,  second,  as  to  the  subjective  results  bearing  upon  the 
relief  afforded  or  new  discomforts  entailed  by  the  operation. 

I  do  not  propose  to  make  an  exhaustive  investigation  of  this  subject ;  indeed, 
in  some  other  parts  of  this  book  some  phases  of  the  remote  sequelae  are  espe- 
cially emphasized,  particularly  in  the  chapters  on  Carcinoma,  Hernia,  and  Sus- 
pension of  the  Uterus. 

From  a  broad  humanitarian  standpoint  one  of  the  queries  most  interesting  to 
the  surgeon  is.  How  many  invalided  women  are  restored  again  to  an  active  health- 
ful life  by  surgical  treatment  ?  All  women,  for  example,  with  large  tumors  are 
more  or  less  disabled  in  all  the  relations  of  life,  and  every  successful  operation 
for  their  removal  adds  years  of  useful  life.  It  was  computed  that  Sir  Spencer 
Wells,  by  his  successful  ovariotomies,  gave  back  a  sum  total  of  thousands  of 
years  of  life  to  women,  not  to  mention  the  numerous  children  born  to  those  in 
whom  he  was  able  to  conserve  one  ovary. 

I  have  selected  for  an  inquiry  into  the  remoter  results  a  hundred  cases  of 
chronic  pelvic  inflammatory  disease,  a  class  of  patients  in  whom 
the  subjective  symptoms  are  most  marked  and  the  need  of  operative  relief  is 
often  greatest.  The  operations  were  all  radical  and  the  methods  of  operation 
were  those  of  five  and  six  years  ago,  and  therefore  not  so  perfect  as  at  present, 
and  the  questions  in  each  case  were  answered  at  a  period  of  from  two  to 
three  years  after  operation.  Out  of  the  100  women  I  find  that  63  per  cent  were 
entirely  relieved  by  the  operation,  16  per  cent  expressed  themselves  as 
greatly  relieved,  16  per  cent  were  partially  reheved,  while  4  per  cent  were  in 
the  same  condition  as  before,  and  one  woman  was  worse  after  the  operation 
than  before  it. 

If  drainage  had  not  been  so  extensively  used  as  it  was  at  that  time  the  per- 
centage of  cures  would  have  been  nmch  greater. 

An  increase  in  weight  in  this  group  of  cases  is  almost 
synonymous  with  the  general  improvement,  for  sixty-nine  of 
these  women  gained  in  M'eight  while  twenty  remained  as  before,  eleven  lost 
weight,  and  forty-seven  out  of  the  sixty -nine  reported  a  gain  varying  from  six- 
teen to  twenty-eight  pounds. 


ANATOMICAL   CHANGES.  521 

Anatomical  Changes. — The  incision  in  the  abdominal  wall  is  the  one  feature 
common  to  all  ceHotomies,  and  it  is  a  question  of  importance  to  determine  what 
permanent  disadvantages  may  arise  from  it.  The  four  chief  disturbances  liable 
to  occur  at  a  later  date  from  the  incision  are  hernia,  suppuration,  marked  en- 
largement of  the  scar,  and  a  tender  scar. 

Hernia  is  one  of  the  most  distressing  sequelae,  causing  the  patient  constant 
discomfort  when  erect,  limiting  to  a  great  degree  her  activity,  and  even  endan- 
gering life  from  incarceration  of  the  bowel  in  the  sac.  I  have  seen  a  patient 
seventj-iive  years  old  die  from  a  strangulated  incarcerated  hernia,  the  sequel  of 
an  ovariotomy  performed  by  Dr.  John  Atlee,  of  Lancaster,  Pa.,  twenty-seven 
years  ago.  The  patient  was  bedfast  after  her  operation  from  Oct.,  1869,  to 
Feb.,  1870,  on  account  of  the  suppuration  of  the  abdominal  wound,  and  on  get- 


Fio.  590. — Strangulated  Hernia  in  a  Patient  75  Years  Old,  die  to  (Ovariotomy  27  Years  before. 

The  intestines  within  the  abdomen,  proximal  to  the  sac,  were  greatly  distemled,  and  there  was  moderate 
distention  within  the  sac,  but  at  the  neck  of  the  sac  the  bowel  was  narrowed  down  to  a  little  yellow  rigid 
tube  almost  without  a  lumen. 

ting  up  she  liad  a  large  incarcerated  ventral  hernia.  She  suffered  from  frequent 
mild  attacks  of  obstruction  until  the  final  severe  attack  of  complete  obstruction 
in  which  I  saw  her.  She  was  then  vomiting  fecal  matter,  and  while  under  the 
anesthetic,  being  prepared  for  an  operation  on  the  irreducible  hernia,  she  sud- 
denly poured  out  such  a  deluge  of  fecal  matter  into  her  throat  and  nose  that  she 
died  at  once  of  suffocation.  At  the  post-mortem  examination,  which  was  now 
made  in  place  of  the  operation,  a  large  ventral  hernia  was  opened  with  two  prin- 
cipal loculi ;  in  the  left  was  about  a  foot  of  adherent  strangulated  bowel,  which 
was  atrophic  and  narrowed  down  l)y  the  prolonged  ]>ressure  to  a  centimeter  in 
diameter  at  the  neck  of  the  sac;  a  part  of  the  omentum  in  the  sac  was  gan- 
grenous. 

Hernia  is  caused  by  several  factors,  of  M'hich  the  commonc-^t  is  an  infection 
causing  the  wound  to  till  in  slowly  with  scar  tissue  ;  it  was  far  more  frei^uent  in 


522 


THE    MORE    REMOTE    RESULTS    OF    ABDOMINAL    OPERATIONS. 


the  (lavs  when  tlie  abdomen  was  hal)itual]y  drained  after  all  operations,  for  the 
opening  left  by  the  removal  of  the  glass  tube  or  piece  of  gauze  granulated  and 
left  a  weak  point  in  the  walls  liable  to  give  way  at  a  later  date. 

Hernia  is  also  due  to  failure  in  bringing  the  fascia?  into  accurate  apposition 
by  good  suturing ;  in  the  early  days  the  one  object  cleai-ly  before  the  mind  of 
the  operator  was  simply  to  hold  one  side  of  the  incision  over  against  the  opposite 
side  by  a  series  of  interrupted  sutures  passing  through  all  the  layers.  With  the 
knowledge  that  the  strength  of  the  lower  abdominal  wall  lies  in  the  fascia  in 
front  of  the  recti  muscles  has  come  more  accurate  methods  of  suturing  this  layer, 
and  correspondingly  fewer  hernise. 


Area  of  conslrictioa  - 


Mucosa  within  the  sac . 


Fig.  59L — A  Section  through  the  Constricted  Portion  of  the  Bowel  shown  in  Fig.  590. 

Sliowing  tlie  extraordinurv  tliinninc^  of  its  coats  almost  to  complete  severance.  The  mucosa  of  the  bowel 
witliiii  tlie  abdomen  was  normal,  while  witliiu  the  sac  it  was  much  atrophied  in  common  with  the  remaining 
coats.     In  the  ring  the  mucosa  had  disappeared. 

Hernia  is  more  fre(pient  in  women  who  l)ecome  much  stouter  after  operation, 
in  whom  the  intra-abdominal  pressure  is  increased. 

In  rare  instances  a  loop  of  the  l)Owel  slips  under  a  band  of  lymph  and  be- 
comes strangidated,  causing  speedy  death  unless  discovered  and  relieved  by 
oi)eration  (see  Fig.  589). 

I  found  eight  cases  of  hernia  in  one  hundred  of  my  cases  of  pelvic  inflam- 
matory disease ;  these  include  a  variety  of  plans  of  suturing  and  an  excessive  use 
of  drainage.  The  number  of  herni?e  under  the  present  methods  of  suture  and 
the  abandonment  of  drainage  will  not,  I  think,  amount  to  more  than  one  in  a 
hundred,  and  then  only  in  those  cases  when  there  has  been  suppuration  in  the 
abdominal  walls.  In  coniirmation  of  this,  Dr.  W.  W.  Russell  notes  a  remarkable 
decrease  in  the  number  of  hernia  cases  returning  to  the  Johns  Hopkins  Hospital 
Dispensary  within  the  past  three  years.  Since  the  use  of  the  silver-wire  suture 
in  closing  the  fascia  but  three  cases  in  all  have  returned  with  ventral  herniae, 
and  it  is  significant  to  note  that  there  was  an  infection  of  the  abdominal  wound 
in  each  case  while  still  in  the  hospital. 


EXLARGEMENT   OF   THE    SCAR.  523 

Suppuration  of  the  wound  at  a  date  later  than  a  year  is  rare,  though 
occasionally  a  little  pustule  forms  on  the  scar  and  continues  to  discharge  until 
one  of  the  fascial  sutures  is  removed. 

F  i  s  t  u  1 86  and  sinuses  are  now  of  rare  occurrence.  They  were  invari- 
ably the  result  of  infected  drainage  tracts  and  sutures,  and  were  most  frequently 
associated  with  extensive  inflammatory  disease  of  the  appendages.  Fecal  iis- 
tulfe  are  at  times  caused  by  infected  sutures  lying  in  contact  with  the  bowel, 
ulcerating  their  way  into  its  lumen.  Deep-seated  persistent  sinuses  are  also 
due  to  sutures.  Such  tracts  may  discharge  for  months  and  years,  until  the 
suture  is  taken  out  or  comes  away,  when  they  often  close  spontaneously. 

Enlargement  of  the  Scar , — If  the  patient  gains  weight  rapidly  and 
the  girth  of  the  abdomen  increases,  the  scar  will  yield  from  side  to  side  until  it 
becomes  one  or  two  or  more  centimeters  broad  ;  it  is  often  pitted  and  pigmented 
and  unsightly.  I  know  of  nothing  to  improve  this  condition,  and  do  not  believe 
that  the  bandage  is  of  any  material  assistance.  Some  observers  have  noted  the 
formation  of  a  large  keloid  in  the  scar. 

Tender  Scar  . — Soreness  and  shooting  pains  in  the  scar  are  common  while 
the  wound  is  young  and  pink ;  in  nervous  patients  the  tenderness  may  persist 
for  years.  Relief  will  be  best  attained  by  gentle  massage  and  by  arranging  the 
clothing  so  as  to  avoid  all  direct  pressure  on  the  sensitive  area. 

Alteration  in  the  position  of  the  intestines  is  perhaps  the 
most  constant  of  all  the  changes  induced  by  the  removal  of  pelvic  viscera ; 
additional  loops  of  the  intestines  drop  into  the  pelvis  to  fill  the  vacated  space, 
producing  a  pelvic  enterocele.  For  the  normal  intestinal  relations  see  Vol.  I, 
Chapter  IV. 

Adhesions  of  the  omentum  and  intestines  over  the  inner 
peritoneal  surface  of  the  incision,  although  often  discovered  in  opening  the  ab- 
domen some  years  after  the  original  operation,  can  scarcely  be  classified  among 
the  late  sequelie,  as  they  denote  simply  the  persistence  of  a  condition  which  must 
have  been  Ijrought  about  shortly  after  the  operation.  Such  adhesions  of  the  in- 
testines, or  short  omental  adhesions,  which  drag  down  the  transverse  colon  and 
pull  the  stomach  down  with  it,  have  repeatedly  been  found  to  explain  persistent 
pain  in  the  lower  abdomen,  tormina,  nausea,  and  frequent  vomiting. 

The  release  of  the  adhesions  with  an  aseptic  closure  of  the  abdominal  incision 
has  been  followed  by  immediate  relief  of  all  the  symptoms. 

The  vermiform  appendix  may  become  involved  in  post- 
operative adhesions,  attaching  it  to  the  pedicle  left  in  the  pelvis  and 
causing  severe  pain  in  the  right  iliac  fossa,  with  attacks  simulating  apj^endicitis. 
I  operated  on  a  patient  of  this  kind  whose  right  ovary  had  been  removed  three 
years  before  by  Dr.  Hunter  Robl);  I  removed  an  inflamed  left  ovary  and  the 
uterus,  together  with  the  appendix,  which  hung  over  into  the  pelvis  and  was 
firmly  adherent  at  its  end  to  the  pedicle  on  the  right  side.  Dr.  Hunter  Mc- 
Guire,  of  Richmond,  has  also  operated  upon  two  cases  of  appemlicitis  originat- 
ing in  this  way,  one  of  them  being  a  former  patient  of  my  own,  from  whom  I 
removed  the  appendages  for  inflannnatory  disease. 


524  THE    MORE    REMOTE    RESULTS    OF    ABDOMINAL   OPERATIONS. 

Encysted  peritonitis  following  a  recovery  complicated  by  sepsis 
sometimes  persists  for  months  or  a  year  or  more,  especially  after  operations  for 
pelvic  inflammatory  diseases.  Mutually  adhering  loops  of  intestines  wall  off  a 
part  of  the  pelvis,  usually  to  the  right  or  the  left  side  behind  the  broad  liga- 
ment, and  in  this  sac  a  quantity  of  clear  serum  accumulates ;  sometimes  as  much 
as  half  a  liter  of  fluid  is  found.  As  the  sac  becomes  tense  it  can  readily  be 
palpated  both  by  the  vagina  and  by  the  abdomen,  and  yields  the  signs  of  an  in- 
dependent cystic  tumor.  The  patient  may  have  fever,  shght  chills,  a  quickened 
pulse,  and  severe  pain,  and  is  only  relieved  by  evacuation  of  the  sac. 

Local  Changes. — Following  the  extirpation  of  both  ovaries,  the  uterus 
and  vagina  undergo  the  same  atrophic  changes  we  see  after  the  natural  cessation 
of  menstruation. 

Glaevecke  {Archivf.  Gyn.,  Bd.  xxv)  divides  the  changes  in  the  vagina  pro- 
duced by  castration  into  three  stages  : 

First,  a  hyperemia,  which  shows  a  marked  injection  of  the  mucosa,  soon  be- 
coming soft  and  swollen ;  the  normal  secretion  is  increased,  and  at  times  an  ap- 
pearance is  produced  similar  to  pregnancy.  This  condition  usually  lasts  but  a 
few  months. 

Second,  the  vagina  begins  to  shrink,  becomes  pale,  and  shows  a  few  deep 
brownish-red  patches,  especially  about  the  urethral  orifice ;  occasionally  the 
whole  vagina  is  studded  with  them.  The  patches  do  not  disappear  on  pressure, 
and  they  are  probably  due  to  hemorrhages  from  rupture  of  the  atrophic  vessels 
by  coition.     This  stage  may  last  from  one  to  five  years. 

The  third  stage  is  one  of  general  atrophy.  The  mucous  membranes  become 
white  and  anemic,  the  red  spots  fade,  and  the  color  finally  becomes  a  uniform 
grayish  red.  The  vagina  shortens,  its  lumen  becomes  narrower,  and  its  walls 
stifler.  Coitus  is  sometimes  impossible  on  account  of  the  marked  decrease  in 
size  ;  occasionally  a  slight  vaginal  prolapsus  may  appear. 

I  have  also  seen  a  severe  persistent  granular  colpitis. 

The  changes  in  the  uterus  are  regularly  found,  and  are  more  marked 
than  in  the  other  structures.  The  decrease  in  size  begins  soon  after  the  removal 
of  the  ovaries,  and  progresses  rapidly  and  uniformly  throughout  the  whole  organ, 
which  soon  becomes  harder,  stiffer,  and  less  vascular.  Any  erosion  of  the  cervix 
rapidly  disappears,  and  a  catarrh  may  cease  without  treatment. 

Menstruation. — During  the  period  when  the  tubes  and  ovaries  only  were 
remcned  on  account  of  inflammatory  disease,  menstruation  not  infrequently 
persisted,  either  appearing  at  the  usual  time  or  as  an  irregular  uterine  hemor- 
rhage ;  but  since  it  has  been  the  rule  to  remove  the  uterus  with  the  tubes  and 
ovaries  in  all  cases  where  it  is  necessary  to  remove  the  appendages  the  cessation 
of  the  menstrual  function  has  l)een  in  most  cases  immediate  and  absolute.  I 
know  of  two  cases  of  persistent  cervical  menstruation  after  a  supravaginal  am- 
putation of  uterus,  tubes,  and  ovaries,  one  a  patient  of  Dr.  "W.  E.  Ashton  and 
one  of  my  own.  Various  reasons  were  wont  to  be  assigned  for  a  regular  per- 
sistence of  menstruation,  but  it  is  probable  that  in  every  instance  some  ovarian 
tissue  is  left. 


AKTIFICIAL    MEXOPAUSE. 


525 


Out  of  seventy-nine  of  my  cases  of  inflammatory  disease  of  the  appendao-es 
investigated  by  Dr.  W.  W.  Russell  from  two  to  three  years  after  the  operation, 
he  found  that  forty-six  of  them  ceased  menstruating  at  once,  twenty-three  con- 
tinued to  have  a  regular  flow  for  several  years,  while  nine  had  irregular  hemor- 
rhages at  intervals  of  from  one  to  twelve  months. 

I  have  several  times  been  obliged  to  open  the  abdomen  on  account  of  severe 
dysmenorrhea  and  pelvic  pain  after  removal  of  the  tubes  and  ovaries,  and  in 
each  case  have  found  little  nodules  the  size  of  a  pea  or  larger  at  either  uterine 
cornu,  or  attached  to  the  stump  on  the  broad  ligament.  These  masses  have  in- 
variably proved  to  be  made  up  of  ovarian  tissue  showing  follicles  and  corpora 


Fig.  592. — Showixo  the  Ends 


OF  THE  Tlbes  axd  Pieces 
Operation. 


OF    THE    (J\A1;Y     LLl  1     AITEU    AX    liU'EHFECT 


The  patient  came  to  my  clinic,  and  I  reopened  tlie  abdomen  and  found  two  yellow  corpora  at  the  left 
cornu,  with  most  of  the  isthmus  of  the  tube  and  a  large  corpus  nigrum  and  small  corpoia  lutea  and  a  piece  of 
the  tube  on  the  ri^ht  side.  Both  masses  were  excised  as  indicated  by  the  dotted  line  at  the  left  coruu,  and 
the  wound  sutured  as  shown  at  the  right  cornu.     L.  B.,  Oct.  28,  1893.     Natural  size. 

lutea,  and  in  one  case  a  long  piece  of  the  tube  was  also  found  with  the  bit  of 
ovary  at  the  left  cornu.  In  these  cases  the  j)ersistent  menstruation  was  evi- 
dently due  to  an  imperfect  operation. 

Artificial  Menoj^ause . — The  menopause  artificially  produced  by  the 
removal  of  the  ovaries  usually  creates  the  most  distressing  disturbances  ^nth 
which  we  have  to  deal  in  the  after-care  of  our  patients.  They  resemble  the 
symptoms  occurring  at  the  natural  change  of  life,  e.xcept  that  in  most  cases  they 
are  greatly  exaggerated. 

The  first  discomforts  are  generally  noted  after  the  time  for  the  first  period 
has  passed,  and  they  usually  run  a  course  of  from  eighteen  montlis  to  two 
years ;  exceptionally  I  have  known  them  to  continue  for  five  years  or  even 
longer.  Not  all  patients  suffer  these  attacks  in  like  intensity  ;  as  a  general  rule, 
neurasthenic  women  seem  to  suffer  the  most,  and  the  nearer  the  patient  is  to 
her  natural  menopause  the  less  the  severity  of  the  symptoms. 


526  THE    MORE    REMOTE    RESULTS    OF    ABDOMINAL    OPERATIONS. 

Waves  of  heat  and  flushes  are  the  commonest  sequelge,  commg  often  at 
variable  intervals  of  a  few  minutes  only  or  several  hours ;  tliej  pass  over  the 
whole  body  like  a  wave  of  hot  air ;  the  face  may  become  visibly  reddened,  and 
there  is  a  transient  cardiac  palpitation  and  sometimss  a  sense  of  giddiness. 
Each  attack  lasts  from  half  a  minute  to  several  minutes. 

After  the  flushing,  the  skin  is  often  bedewed  with  a  gentle  perspiration,  and 
a  sense  of  relaxation  and  exhaustion  is  felt ;  in  rarer  instances  the  perspiration 
is  profuse  enough  to  saturate  the  niglitdress,  leaving  the  patient  cold  and 
shivering. 

A  case  referred  to  me  by  the  operator  (S.  T.  W.,  aged  thirty-tive,  Feb.  16, 
1897),  affords  a  good  picture  of  these  distressing  psychic  sequelae.  Both  ova- 
ries were  removed  eight  months  before,  the  recovery  being  complicated  by  pro- 
fuse suppuration  in  the  abdominal  wound.  She  had  previously  always  been 
of  a  notably  cheerful  disposition.  Suddenly,  about  two  weeks  after  the  oper- 
ation, a  deep  gloom  came  over  her  "like  a  flash  of  lightning,"  and  she  was 
fully  persuaded  that  she  was  dying ;  she  had  at  the  same  time  "  a  giving  away 
cold  feeling  which  lasted  three  days."  She  has  been  since  then  extremely 
nervous,  and  suffers  from  a  confusion  of  ideas  and  inability  to  concentrate  her 
mind.  She  has  lost  all  confidence  in  herself  and  all  interest  in  life,  and  never 
has  her  old  sense  of  buoyancy,  nor  does  she  care  as  before  for  reading  and 
music.  She  has  "  untold  miserable  feelings,  almost  amounting  to  torture."  Her 
face  is  blotched,  and  she  has  itching  of  the  head  and  nose  and  anesthesia  of  the 
hands  and  face.  Flushes  are  not  troublesome  and  headaches  not  marked.  I 
found  on  making  an  examination  that  the  vagina  was  uniformly  injected,  rose- 
red,  and  bathed  with  a  whitish  discharge  ;  the  cervix  was  normal  and  the  fundus 
large,  anteverted,  and  not  sensitive. 

Many  j^atients  are  distinctly  benefited  at  this  time  and  the  severity  of  the 
attacks  modified  by  taking  bitter  tonics.  I  would  particularly  recommend  the 
following  pill  taken  three  times  a  day  :  Stryeh.  sulph.,  gr.  3^;  atropia  sulph.,  gr. 
-j-Jq-;   ext.  columbo,  gr.  1. 

Some  patients  after  complete  cessation  of  the  menstrual  period  have  typical 
menstrual  molimina  at  the  time  menstruation  would  have  appeared ;  these 
symptoms  usually  disappear  in  a  few  months.  Eecently  experiments,  the  results 
of  which  are  as  yet  uncertain,  have  been  made  to  obviate  these  symptoms  by 
implanting  small  portions  of  ovarian  tissue  in  the  abdominal  incision. 

I  have  for  these  i-easons  left  the  ovaries  in  in  all  my  cases  of  hystero -myo- 
mectomies in  women  under  forty,  and  have  noted  in  each  case  that  the  patients 
did  not  experience  such  distressing  sequeli^. 

Schmalfuss  {Zu/'  Castration  bei  NeuroHen^  Archivf.  Gyn.,  Bd.  xxvi,  No.  1) 
divides  the  neuroses  into  three  groups  : 

1.  Symptoms  referred  to  the  lumbar  section  of  the  spinal  cord,  such  as  throb- 
bing and  pain  in  the  back,  pain  in  the  iliac  region,  pain  extending  from  the 
back  to  the  abdomen  and  radiating  down  the  thighs,  pressure  in  the  pelvis, 
downward  tugging,  anesthesia  and  hyperesthesia  of  the  vagina  and  vulva,  and 
pain  on  urination  and  defecation. 


INSANITY.  527 

2,  Besides  those  mentioned,  other  neurotic  symptoms  appear  which  are  re- 
ferred to  different  parts  of  the  body,  such  as  cardialgia,  pressure  in  the  epigas- 
trium, sensation  of  fullness,  belching,  vomiting,  and  globus. 

3,  A  distinct  neuropathic  condition,  general  pain,  vaso-motor  disturbances, 
vicarious  menstruation,  respiratory,  gastric,  and  intestinal  attacks  of  various 
sorts,  cramps,  and  epileptiform  convulsions. 

Many  of  these  results  are  often  due  to  inflammatory  sequelae  and  adhesions 
forming  after  the  operation. 

Insanity. — Insanity  is  the  most  appalling  of  all  the  sequelae  which  may  follow 
a  gynecological  operation  ;  there  is,  however,  nothing  peculiar  in  this  association, 
for  it  also  occurs  after  operations  in  general  surgery,  and  indeed  has  been  ob- 
served to  follow  a  simple  fracture  (Dr.  F.  J,  Shepherd,  of  Montreal),  and  even 
the  use  of  an  anesthetic  without  any  operation  at  all.  One  of  my  cases,  a  colored 
girl,  became  insane  after  an  asej)tic  abortion.  It  has  often  been  noted  after' 
such  simple  plastic  operations  as  repair  of  the  vaginal  outlet.  I  have  seen  six 
cases  of  insanity  following  perineal  operations,  one  of  whom  died  in  acute  mania ; 
another  case,  operated  upon  for  lacerated  cervix  and  a  relaxed  vaginal  outlet, 
committed  suicide  after  returning  home  by  drinking  pure  carbolic  acid.  A  col- 
ored woman,  a  case  of  curettage  for  carcinoma  of  the  cervix,  died  in  an  insane 
asylum. 

I  have  seen  insanity  after  abdominal  operations  in  eight  cases  out  of  some- 
thing over  two  thousand  abdominal  sections — that  is,  an  average  of  one  half  of 
one  per  cent — 

An  analysis  of  a  series  of  cases  shows- — • 

1.  That  the  attack  of  insanity  may  immediately  follow  the  operation  (one 
case),  or  be  developed  at  an  interval  of  from  a  few  days  to  several  weeks. 

2.  That  the  attack  is  not  due  to  a  septic  poison  is  shown  by  the  simple  im- 
complicated  recovery  as  far  as  the  field  of  operation  is  concerned. 

3.  That  it  does  not  arise  from  the  occurrence  of  bad  sequelae  of  any  sort  con- 
nected with  the  operation,  such  as  exhaustion  from  hemorrhage,  or  a  protracted 
operation,  or  severe  suffering  after  the  operation, 

4.  That  the  insanity  may  follow  any,  even  the  simplest  operation,  or  even  no 
operation  at  all.  Insanity  is  more  frequent  after  simple  than  after  grave  opera- 
tions. The  removal  of  ovaries  and  tubes,  and  with  the  removal  the  ablation  of 
their  function,  does  not  appear  to  stand  in  any  causative  relation. 

5.  Exfoliative  cystitis  was  the  symptom  most  prominent  in  one  of  my  pa- 
tients. Dr.  C.  P.  Noble,  of  Philadelphia,  has  noted  excessive  irritability  of  the 
bladder  in  several  of  his  cases  of  post-operative  insanity. 

6.  Patients  most  apt  to  become  insane  after  operation  are  for  the  most  part 
women  who  have  been  excessively  apprehensive  about  the  result  of  operation  or 
its  effect  on  their  minds,  also  neurotic  and  hysterical  women. 

7.  A  most  marked  predisposition  exists  in  women  who  have  been  previously 
melancholy  and  insane,  and  any  patient  with  this  blot  in  lier  history  should  only 
be  operated  upon  in  case  of  urgent  necessity,  and  with  the  fullest  explanation  to 
the  family  as  to  the  risk  incurred. 


52S  THE    MORE    REMOTE    RESULTS    OF   ABDOMIXAL   OPERATIONS. 

8.  Eecovery  may  take  place  in  a  few  weeks  or  only  after  several  years. 
There  is,  as  a  rule,  a  slow  progression  from  worse  to  better,  from  greater  to  less 
A-iolenee  and  noisiness  ;  at  other  times  the  iirst  symptoms  of  improvement  are 
intervals  of  lucidity  which  increase  in  frequency  and  duration.  Kot  infrequently 
the  insanity  is  permanent. 

Of  my  own  eight  cases,  five  recovered  completely,  two  remained  insane,  and 
one  committed  suicide  after  her  return  home. 

Dr.  C.  P.  Noble  has  furnished  me  with  an  analysis  of  sixteen  cases  occurring 
in  his  practice  ;  six  of  these  were  insane  or  had  had  delusions  before  the  opera- 
tion, two  of  whom  recovered,  while  in  four  the  mental  condition  remained  un- 
changed. In  six  other  cases  the  mental  condition  was  normal  before  operation ; 
these  were  followed  either  by  delusions  or  by  hysterical  mania,  and  all  recov- 
ered. In  the  remaining  four  eases  there  had  been  attacks  of  hystero-epilepsy 
before  the  operation  ;  two  of  these  patients  were  cured,  one  continued  to  have 
attacks,  and  the  remaining  one  had  true  epilepsy. 

Two  other  kindred  questions  worthy  of  careful  consideration  are  these : 
whether  gynecological  ailments  can  act  as  the  jjrovoking  causes  of  insanity,  and 
whether  it  is  possible  to  cure  or  ameliorate  the  condition  of  insane  patients  by 
treating  such  gynecological  ailments  as  they  may  have. 

In  the  Maryland  Hospital  for  the  Insane,  Dr.  George  H.  Kohe  found  local 
lesions  demanding  operation  in  forty  out  of  one  hundred  women  {Jour,  of  the 
Amer.  Med.  J..y.y.,  Oct.  12,  1895). 

"  In  thirty  of  these,  abdominal  section  with  removal  of  the  nterine  appen- 
dages was  practiced.  Two  cases  were  subjected  to  primary  vaginal  total  extir- 
pation of  uterus  and  appendages.  In  two  repair  of  the  lacerated  cervix  was 
done.  In  six  the  guardians  of  the  patients  would  not  consent  to  operation.  Of 
the  thirty  abdominal  sections  there  were  cured  physically  and  mentally,  ten  ; 
decidedly  improved,  four ;  unimproved,  thirteen  ;  died,  three. 

"  Of  three  secondary  vaginal  hysterectomies,  which  are  included  among  the 
thirteen  unimproved  after  removal  of  the  ajjpendages,  one  was  cured  and  two 
remained  as  before.  Of  the  two  primary  total  extirpations,  one  was  cured  and 
the  other  so  much  improved  as  to  give  strong  hope  of  ultimate  mental  recov- 
ery.    The  two  trachelorrhaphies  Ijoth  recovered,  mentally  and  physically. 

"  The  final  results  of  the  operations  at  present  are,  therefore,  cured  (physi- 
cally and  mentally),  fourteen  ;  improved,  five  ;  unimproved,  twelve  ;  died,  three. 
Total,  thirty-four." 

Dr.  Rohe  goes  on  to  discuss  the  indications  as  follows  : 

"  In  what  class  of  cases  is  an  operation  indicated  ?  Where  there  is  local 
disease  discoverable  on  examination.  The  mental  symptoms  themselves  are  no 
guide.  Mania,  melancholia,  confusional  insanity,  hystero-epilepsy,  have  all  been 
cured.  The  same  forms  of  mental  disturbance  have  sometimes  not  been  bene- 
fited. In  consecutive  dementia  and  in  epilepsy,  where  brain  deterioration  has 
already  occurred,  no  improvement  can  be  looked  for  in  the  psychic  symptoms. 
I  believe  that  in  some  cases  of  cjjilepsy  where  thei-e  is  pelvic  irritation  an  early 
removal  of  the  source  of  the  irritation  would  be  of  benefit  to  the  patient.     In 


INSANITY.  529 

all  cases,  however,  where  local  disease  exists,  appropriate  treatment  is  indicated 
irrespective  of  the  mental  condition.  Thus  all  three  of  the  cases  who  died  were 
of  dementia,  two  consecutive  to  epilepsy.  In  all  of  these  there  was  abundant 
local  disease  to  demand  interference.  In  one  there  were  large  pus  tubes  and 
ovarian  abscesses  matting  all  the  pelvic  organs  into  a  mass  infiltrated  with  pus. 
In  another  there  was  an  intraligamentous  cyst  as  large  as  an  orange.  The  third 
case  was  a  large  fibroid  tumor. 

"  Twelve  of  the  recovered  cases  have  been  discharged  and  all  but  one  are 
alive,  and,  so  far  as  I  have  been  able  to  ascertain,  remain  in  physical  and  mental 
health.     Two  are  still  under  observation  in  the  hospital. 

"  The  clinical  variety  of  mental  disturbance  in  the  recovered  cases  was :  puer- 
peral insanity  (mania),  four  ;  melancholia,  six  ;  mania,  three  ;  hystero-epilepsy, 
one.     Total,  fourteen, 

"  In  the  cases  in  which  complete  recovery  did  not  follow  the  operative  meas- 
ures, there  were  of  melancholia,  two  ;  mania,  five  ;  puerperal  msanity  (mania), 
one  ;  dementia  (including  four  of  epilepsy),  seven  (three  deaths) ;  paranoia,  two ; 
hysterical  insanity,  two  ;  adolescent  insanity,  one.     Total,  twenty. 

"  The  number  of  my  cases  is  too  small  to  allow  one  to  draw  any  conclusions, 
but  if  anything  of  practical  value  can  be  deduced  from  them,  it  is  that  puer- 
peral insanity,  melancholia,  and  simple  mania  offer  the 
best  chances  of  cure  from  the  proper  treatment  of  local 
lesions  in  the  pelvis.  Of  course  it  may  be  said  that  these  forms  of 
mental  disorder  are  just  those  which  yield  in  the  majority  of  cases  to  the  usual 
methods  of  management  of  insanity.  In  seven  of  the  cases,  however,  the  insanity 
had  lasted  over  eighteen  months  before  any  treatment  directed  to  the  local  lesion 
had  been  instituted.  In  a  case  of  hystero-epilepsy  the  patient  had  been  in  the 
hospital  seven  years,  and  one  of  the  cases  of  puerperal  insanity  had  been  four 
and  a  half  years  insane.  I  am  convinced  that  earlier  operation  in  appropriate 
cases  would  very  largely  increase  the  proportion  of  recoveries." 

Dr.  W.  P.  Manton,  of  Detroit,  Mich.,  who  was  the  first  gynecologist  in  the 
country  to  be  appointed  on  the  staii  of  an  insane  asylum,  summarizes  his  expe- 
rience in  the  following  words  in  a  letter  dated  Dec.  17,  1890  : 

"  During  the,  past  ten  years  or  so  a  very  large  number  of  insane  women  have 
passed  under  my  observation  in  the  various  mstitutions  with  which  I  am  connect- 
ed, and  I  have  had  opportunities  to  do  the  various  abdominal,  vaginal,  etc.,  oper- 
ations, and  note  their  effect,  AVe  long  ago  came  to  the  conclusion  that  the  idea 
of  restoring  the  sick  mind  to  health  as  the  result  of  gynecological  operative  in- 
terference should  be  abandoned.  Such  operations  are  therefore  now  undertaken 
solely  for  the  relief  of  somatic  coiulitions.  An  operation  may  act  as  one  of  the 
factors  in  bringing  about  a  mental  cure,  but  I  believe  that  it  must  always  be 
done  early,  and  associated  with  such  other  treatment  in  the  way  of  medicines, 
food,  quiet,  rest,  etc.  After  degenerative  processes  have  occurred  in  the  brain, 
I  believe  that  it  is  useless  to  look  for  mental  cure.  I  can  say  this,  however :  I 
have  never  operated  on  an  insane  woman  yet,  no  matter  to  what  extent  demen- 
tia has  gone  on,  without  some  relief  to  the  mental  condition  and  a  decided  im- 


530  THE    MORE    REMOTE    RESULTS    OF    ABDOMIXAL    OPERATIONS. 

provement  in  the  personal  comfort  of  the  patient.  I  have  always  been  very 
conservative  regarding  operative  measures  undertaken  in  insane  cases,  and 
beheve  that  we  can  not  be  too  cautious  in  this  respect. 

"  It  is  our  aim,  at  the  Eastern  Asylum  at  least,  to  discharge  '  cured '  patients 
with  all  their  bodily  ailments  relieved  as  far  as  possible." 


CHAPTER  XXXYIII. 

ON  THE  CONDUCT  OF  AUTOPSIES,  THE  MAKING  OF  PROTOCOLS,  AND 
THE  PRESERVATION  OF  TISSUES  FOR  MICROSCOPIC  EXAMINATION 
IN   GYNECOLOGICAL   PRACTICE. 

1.  Importance  of  autopsies  in  cases  of  death  in  gynecological  practice. 

2.  Method  of  conducting  an  autopsy  :  1.  External   inspection.     2.  Central  nervous  system  (brain 

and  spinal  cord).  3.  Abdominal  viscera.  4.  Thoracic  organs,  plur<T?,  lungs,  pericardium, 
heart,  etc.  5.  Intestines.  6.  Pelvic  organs.  7.  Spleen,  gall  bladder,  stomach,  liver,  mes- 
entery. 8.  Ui'inary  and  genital  organs.  9.  How  to  close  up  a  body.  10.  Description  of 
the  findings  at  an  autopsy. 

■3.  Preservation  of  tissues  for  microscopic  examination.  1.  Fixing  agents :  a.  Strong  alcohol. 
b.  Miiller's  fluid.  2.  Other  methods  of  fixing:  a.  With  corrosive  sublimate,  b.  With 
formalin. 

4.  Protocol  I.     Death  without  operation.     J.  J.,  Feb.  1,  1890. 

•5.  Protocol  II.     Death  six  days  after  ojjeration.     M.  E.  S.,  Jan.  27,  1893. 

■6.  Protocol  III.    Death  over  fifty-one  days  after  a  minor  operation.     M.  H.,  March  30,  1893. 

Importance  of  Autopsies  in  Cases  of  Death  in  Gynecological  Practice. — Wlien 
a  death  occurs  in  his  gynecological  practice  the  physician  can  usually,  with 
the  aid  of  a  little  tact,  overcome  the  objections  of  the  friends  of  the  deceased 
and  secure  permission  for  the  making  of  an  autopsy.  On  the  importance  of 
studying  the  exact  nature  of  the  lesions  in  every  case  of  death,  whether  oc- 
curring independently  of  operation  or  subsequent  to  operative  interference,  it  is 
superfluous  to  insist  here.  The  list  of  morbid  processes  and  of  surgical  acci- 
dents is  so  Ions:,  and  the  variations  which  are  possible  in  any  individual  disease 
are  so  manifold,  that  after  one  has  taken  advantage  of  every  opportunity  for 
■observation  offered  at  a  large  hospital  he  is  compelled  to  confess  that  even  then 
he  has  barely  begun  to  get  an  insight  into  the  pathology  of  the  uterus  and  its 
-adnexa. 

Methods  of  conducting  an  Autopsy. — Whenever  it  is  possible  the  autopsy 
should  be  made  by  an  experienced  pathologist,  the  surgeon,  of  course,  being 
present  to  watch  each  step  in  the  procedure.  Taking  the  clinical  history  of 
the  case  as  a  guide,  it  should  be  the  object  of  the  examiner  not  only  to  find  out 
the  immediate  cause  of  death,  l)ut  also  to  explain  as  definitely  as  possible  the 
nature,  the  origin,  and  the  sequence  of  all  the  deviations  from  the  normal  which 
may  be  present  in  the  cadaver.  Where,  for  instance,  a  patient  has  died  with 
symptoms  of  an  acute  infection,  a  careful  general  and  special  consideration  of  all 
the  conditions  and  lesions  present  must  be  supplemented  l»y  a  complete  bac- 
teriological examination,  in  order  that  we  may  determine  not  oidy  the  exciting 
cause  of  the  infection — the  micro-organism  or  micro-organisms  concerned — but 
Also  tlie  portal  of  entry  through  which  the  bacteria  have  gained  access  to  the 
77  531 


532  ON   THE    CONDUCT   OF   AUTOPSIES. 

tissues,  the  nature  of  the  breach  in  the  normal  niechanisnis  of  defense  by  which 
this  ingress  was  rendered  possible,  and  finally  the  conditions  underlying  the  in- 
sufficiency in  the  resisting  power  of  the  cells  and  tissue  fluids  of  the  body, 
which  permitted  the  infection  when  once  in  progress  to  lead  to  a  fatal  ter- 
mination. 

An  autopsy  made  with  such  ends  in  view  is  by  no  means  a  light  task.  Not 
a  little  time  and  thought  will  be  required,  and  if  thorough  bacteriological  and 
microscopic  examinations  be  made,  it  may  be  weeks  before  the  pathologist  has 
completed  his  investigations  and  is  prepared  to  pass  final  judgment  upon  the 
case.  Too  often,  even  then,  a  whole  series  of  phenomena,  will  remain  unex- 
plained, for  in  pathology,  as  in  any  other  science,  the  work  done  in  the  solu- 
tion of  one  question  usually  brings  to  light  the  existence  of  other  problems 
which,  for  the  time  being  at  least,  can  not  be  solved. 

It  is  now  generally  recognized  that  really  thorough  and  satisfactory  autop- 
sies can  only  be  conducted  in  the  special  pathological  institutions,  where  the 
workers  can  give  all  their  time  to  pathological  work,  and  the  practitioner  must 
be  content  to  approach  as  nearly  as  possible  to  ideal  autopsy  methods. 

The  exact  course  to  be  followed  in  a  given  autopsy  necessarily  depends  to  a 
certain  extent  upon  the  attending  circumstances — for  example,  upon  the  time  at 
one's  disposal,  upon  the  extent  of  the  permission  obtained  from  the  friends  as 
regards  completeness  or  incompleteness,  but  more  especially  upon  the  nature  of 
the  suspected  lesions.  If  through  hurry  on  the  part  of  the  friends  the  cadaver 
must  be  delivered  within  a  few  minutes,  the  organs  after  a  quick  survey  may 
be  removed  en  inaH><e  and  studied  in  detail  at  leisure.  If  permission  for  a  com- 
plete autopsy  can  not  be  obtained,  the  operator  may  have  to  be  content  with  the 
examination  of  the  thoracic  and  abdominal  organs  alone.  In  case  of  death 
following  an  abdominal  section,  the  permission  simply  to  reopen  the  wound  will 
sometimes  be  granted  when  a  request  for  a  more  complete  autopsy  is  refused. 
Such  incomplete  autopsies  are  always  more  or  less  unsatisfactory ;  nevertheless, 
in  many  instances  there  is  much  to  be  learned  from  them,  and  on  the  principle 
rhat  "  half  a  loaf  is  better  than  no  bread  "  it  would  be  a  wanton  waste  of  mate- 
rial not  to  take  advantage  of  these  opportunities.  In  cases  of  urgency,  where  no 
external  incision  is  permitted,  one  or  more  organs  or  pieces  of  organs  can,  when 
desired,  be  obtained  through  the  rectum.  (See  H.  A.  Kelly,  On  a  Method  of 
Pod-tnortem  Examination  of  the  Thoraeie  and  Ahdominal  Viscera  throtigh 
Vagina,  Perineum,  and  Rectum,  and  without  Incision  of  the  Ahdominal  Pa- 
rietes  ;  Medical  Neios,  June  30,  1883.) 

In  order  to  attain  skill  in  making  autopsies  there  is  only  one  means — long 
practice.  A  pathologist,  through  years  of  experience,  learns  to  vary  his  tech- 
nique and  routine  according  to  the  nature  of  the  case  before  him  ;  one,  how- 
ever, who  makes  only  an  occasional  autopsy  will  probably  do  best  to  follow 
more  or  less  strictly  a  definite  system,  departing  from  this  only  when  the  nature 
of  the  lesions  renders  nonconformity  unavoidable.  Just  as  in  the  clinical  ex- 
amination of  a  patient  by  a  physician,  so  in  the  investigation  of  diseases  at  au- 
topsy the  rigid  adherence  to  a  definite  routine  leads,  in  the  case  of  the  beginner,. 


METHODS    OF    COXDUCTIXG    AN    AUTOPSY.  533 

at  all  events,  to  the  discovery  of  many  abnormalities  which  otherwise  would 
easily  be  overlooked. 

Of  the  numerous  good  methods  which  have  been  advised,  it  matters  not 
much,  perhaps,  which  one  is  adopted.  In  any  case,  the  examination  begins  with 
a  careful  inspection  of  the  exterior  of  the  body,  the  size  and 
general  structure  are  noted,  and  any  abnormal  appearances  in  the  skin  in  con- 
nection with  the  orifices  of  the  body  or  with  the  peripheral  sense  organs  are  de- 
scribed. As  a  rule,  the  central  nervous  system  is  next  examined,  providino-  the 
autopsy  is  to  be  a  complete  one,  the  brain  being  first  removed  and  afterward 
the  spinal  cord.  If  the  examination  does  not  include  the  central  nervous  svs- 
tem,  the  linear  incision  in  the  middle  line,  extending  from  the  supra-ster- 
nal notch  to  the  pubes,  follows  immediately  upon  the  external  inspection  of 
the  body.  As  the  abdomen  is  opened  and  the  soft  parts  are  dissected  from  the 
ribs,  the  examiner  notes  the  appearance  of  the  subcutaneous  fat,  of  the  muscles^ 
and  particularly  of  the  blood  in  the  vessels.  After  smear  coverslip  preparations 
and  cultures  have  been  made  from  the  fluid  in  the  peritoneal  sac,  a  carefal  in- 
spection of  the  abdominal  and  pelvic  cavities  and  their  contents  follows,  a  part 
of  the  examination  of  the  utmost  importance  to  the  abdominal  surgeon,  and  one 
too  often  hurriedly  or  carelessly  made.  In  this  preliminary  inspection  of  the 
peritoneal  cavity  the  structures  are  to  be  examined  as  far  as  possible  without 
handling  and,  above  all,  without  disturbance  of  the  relations  of  the  different 
parts  to  one  another.  One  notes  the  color,  odor,  and  amount  of  fluid  in  the 
cavity,  its  consistence  and  location,  and  the  presence  or  absence  of  abnormal 
constituents  in  it.  It  may  be  necessary  to  set  aside  a  portion  of  it  in  a  clean 
vessel  for  chemical  and  microscopical  examination.  The  position  of  the  organs, 
their  color,  vascularity,  and  consistence  can,  as  a  rule,  be  easily  determined  with- 
out disturbing  the  general  relations.  If  hemorrhage  has  occurred,  the  origin 
and  extent  of  the  bleeding  must  be  ascertained,  and  if  extra-uterine  pregnancy 
is  suspected  the  embryo  nnist  be  carefully  sought  for. 

The  accurate  and  minute  examination  of  the  surface  of  the  peritoneum  itself 
can  hardly  be  too  strongly  insisted  upon.  Now  that  the  processes  of  bacterial 
infection  are  l)ettei'  understood,  the  patholos-ist  has  learned  to  look  more  closely 
for  slight  evidences  of  inflanunation  in  the  ])eritoneiim.  It  is  now  an  estab- 
lished fact  that  a  most  virulent  infection  of  the  peritoneum,  leading  in  a  few 
hours  to  death,  is,  as  a  rule,  accompanied  by  less  marked  local  and  tangil)le  signs 
than  are  to  be  found  in  those  which  have  had  a  slower  course.  Often  the  only 
sign  of  a  peritonitis  to  be  made  out  is  an  extremely  delicate  fibrinous  deposit 
which,  over  limited  areas,  deadens  almost  imperceptibly  the  normal  gloss  of  the 
peritoneum,  or  again  we  may  have  only  a  slight  injection  of  the  blood  vessels 
in  certain  places,  especially  where  the  individual  loops  come  into  contact  with 
one  another.  In  such  instances  a  superficial  observation  would  entirely  fail  to 
bring  to  light  a  most  important  pathological  change.  It  is  surprising  to  find 
how  many  cases  of  chronic  disease  exhibit  at  autopsy  evidences  of  a  final  infec- 
tion which  has  attacked  the  peritoneum  and  has  been  accompanied  by  such 
insignificant  phenomena  as  those  just  mentioned,  and  which  was  not  in  the  least 


534  ON   THE   CONDUCT   OF    AUTOPSIES. 

suspected  during  life.  It  is  even  claimed  that  an  acute  bacterial  infection  of 
the  peritoneum  may  occur  without  any  associated  exudation.  Under  these  cir- 
cumstances, the  practical  bearing  of  which  is  obvious,  an  examination  by  micro- 
scopic or  cultural  methods  would  alone  suffice  to  make  the  condition  clear.  In 
doubtful  cases  the  examination  of  the  fluid  in  the  peritoneal  cavity  is  of  so  much 
interest  that  one  should  take  care  that  it  is  not  accidentally  neglected. 

An  infection  of  the  peritoneum  being  present,  its  starting  point  can  gener- 
ally, though  not  always,  be  determined.  In  ojDerative  cases  the  process,  by  the 
nature  of  the  lesions,  may  sometimes  be  referred  to  the  external  wound,  to  a 
stitch  abscess,  or  to  a  drainage-tube  ;  in  other  cases  an  infected  ligature,  the 
stump  of  a  pedicle,  or  a  wound  of  the  intestinal  wall  may  be  held  directly 
responsible.  In  cases  of  peritonitis  coming  to  autopsy  without  operation  a 
careful  search  will  also  usually  reveal  the  portal  of  entrance,  whether  it  be  a 
perforation  or  fracture  of  the  wall  of  the  stomach,  intestine,  or  appendix,  or 
a  simple  extension  of  an  infection  from  another  organ  (ovary.  Fallopian  tube, 
uterus,  spleen,  liver,  or  kidney).  Sometimes,  however,  no  satisfactoi'y  explana- 
tion of  the  etiology  is  possible,  and  we  are  forced  to  assume  an  infection  through 
the  blood  current,  or  to  confess  our  ignorance  of  the  cause  altogether.  In  cases 
of  advanced  renal  disease,  such  as  occurs,  for  example,  secondarily  to  pressure 
of  abdominal  tumors  on  ureters,  it  is  claimed  that  a  peritonitis  of  purely  chemi- 
cal origin  may  be  present.  But  it  must  be  remembered  that  an  examination 
for  both  living  and  dead  micro-organisms,  including  the  inoculation  of  animals, 
would  be  necessary  before  the  existence  of  an  infection  in  such  a  case  could  be 
excluded. 

Where  the  peritoneum  is  secondarily  tuberculous  or  cancerous,  a  similar  sys- 
tematic study  of  the  possibilities  of  origin  will  usually  determine  the  relation  of 
the  peritoneal  lesions  to  those  in  other  parts  of  the  body. 

Having  completed  the  preliminary  inspection  of  the  abdominal  cavity  and 
determined  the  level  of  the  diaphragm  upon  the  two  sides,  it  is  customary  to 
proceed  to  the  examination  of  the  organs  in  the  thorax;  the  p  1  e u r se , 
pericardium,  heart,  lungs,  larynx,  and  tr  a  ch  e  a  being  examined 
in  turn.  If  one  is  not  permitted  to  open  the  thorax,  the  examination  of  the  ab- 
dominal organs  may  follow  immediately. 

Having  been  freed  from  the  mesentery  from  the  rectum  to  the  duodenum, 
the  intestine  is  severed  at  both  ends  and  removed  from  the  body.  In  order 
that  no  fecal  matter  may  escape  in  doing  this,  it  is  better  to  tie  it  in  two  places 
at  both  ends,  and  to  cut  between  the  ligatures. 

The  pelvic  organs,  ureters,  kidneys,  and  adrenals  maybe 
removed  together  and  examined.  The  spleen,  bile  duct,  duodenum 
and  stomach,  liver,  gall  bladder  and  pancreas,  larger  blood 
vessels,  mesentery,  lymph  glands,  and  bones  are  then  studied. 

It  would  lead  us  too  far  to  discuss  the  various  methods  employed  in  the  re- 
moval and  examination  of  all  these  organs.  A  little  experience  in  a  good  patho- 
logical lal)oratory  is  of  more  value  than  much  reading  on  the  subject.  If  one  is 
familiar  with  the  normal  appearance  of  the  different  organs  and  tissues  and  can 


METHODS    OF   COXDUCTIXG    AX    ACTOPSY.  535 

recognize  alterations  in  size,  shape,  odor,  color,  and  consistence,  and  in  the  rela- 
tion of  the  different  parts  and  wholes  to  one  another,  he  ^v^ll  have  little  difficulty 
in  detecting  any  abnormaUties  present. 

In  order  to  remove  the  urinary  and  genital  organs  as  a 
whole    one   may   proceed   as   follows: 

The  parietal  peritoneum  lining  the  pelvic  cavity  is  freed  all  around  from 
the  symphysis  pubis  to  the  front  of  the  sacrum  behind.  The  thighs  are  then 
well  spread  apart,  and  an  oval  incision  is  outlined  about  the  external  genitals, 
commencing  in  front  over  the  root  of  the  clitoris,  and  being  continued  on  each 
side  to  a  point  just  behind  the  anus.  The  labia  are  then  seized  with  one  hand 
and  pulled  iirmly  forward  and  downward,  and  the  incision  is  continued  at  the 
upper  angle,  with  a  sharp  scalpel  or  with  curved  scissors,  through  the  tissues 
(including  the  insertions  of  the  corpora  caveniosa  of  the  clitoris)  into  the  pel- 
vic cavity.  Care  must  be  taken  in  cutting  to  keep  close  to  the  border  of  the 
bone  in  order  not  to  mutilate  the  soft  parts.  The  vulva  can  then  be  pushed 
under  the  symphysis  into  the  cavity  of  the  pelvis,  where  it  is  to  be  grasped  with 
the  left  hand  and  lifted  as  high  as  possible.  The  oval  incision  previously  out- 
lined along  the  sides  of  the  labiae  is  now  deepened,  and  with  several  sweeps  of 
the  knife  the  fatty  tissues  and  muscles  on  each  side  of  the  rectum  as  well  as  the 
ligaments  in  front  of  the  coccyx  can  be  severed,  and  the  whole  mass,  including 
bladder,  rectum,  external  and  internal  genitalia,  can  be  lifted  out  and  removed, 
together  with  the  kidneys,  adrenals,  and  uterus. 

In  continuing  the  examination  of  these  parts,  the  organs  should  be  sectioned 
in  such  a  way  that  structures  will  not  be  too  nmch  mutilated  should  it  be  de- 
sirable to  preserve  them  as  museum  specimens.  The  rectum  may  be  split  up 
with  scissors  along  its  posterior  wall  and  examined  first  without  being  washed 
and  again  after  a  thorough  cleansing  with  water.  The  bladder  can  best  be 
opened  by  an  anterior  median  incision  with  knife  or  scissors,  passing  first 
through  the  clitoris  and  its  prepuce,  then  through  the  anterior  wall  of  tlie 
bladder  itself.  After  the  bladder  and  the  ureteral  orifices  have  been  care- 
fully inspected,  the  vagina  and  uterus  can  be  opened  along  their  anterior 
walls  in  the  median  line.  This  cut  of  course  divides  the  bladder  completely 
into  two  halves.  If  there  be  ulceration  or  neoplastic  growths  in  the  bladder, 
and  it  be  desired  to  keep  its  posterior  wall  entire,  the  wall  of  the  uterus  and 
vamna  can  be  cut  throuffh  in  the  middle  line  from  behind ;  in  this  case  the  inci- 
sion  may  either  go  through  the  anterior  wall  of  the  rectum,  dividing  it  into  two 
halves,  or  it  may  be  made  after  dissecting  the  rectum  away  from  the  structures 
in  front  of  it.  The  sagittal  section  of  the  uterus  should  extend  from  the  external 
OS  to  the  fundus.  In  addition,  in  order  to  expose  the  uterine  openings  of  the 
uterine  tubes,  two  small  incisions  may  be  made,  extending  laterally  for  a  suf- 
ficient distance  from  the  upper  extremity  of  the  sagittal  section.  The  uterine 
tubes  may  be  slit  up  with  probe-pointed  scissors,  beginning  at  the  abdominal 
ends  and  passing  inward  to  the  uterine  orifices.  The  ovaries  may  be  cut  in  half 
from  the  posterior  free  surface.  The  kidneys,  after  the  capsule  and  external 
surface  have  been  inspected,  are  cut  into  two  halves  by  an  incision  extending 


536  ox   THE    CONDUCT    OF   AUTOPSIES. 

from  the  cortex  through  to  the  pelvis  along  the  long  diameter  of  the  organ.  The 
ureters  may  be  sht  up  with  scissors  from  the  pelvis  of  the  kidney  to  the  mucous 
membrane  of  the  bladder.  They  should,  however,  always  be  examined  in  situ 
before  the  removal  of  any  of  the  organs ;  otherwise  the  situation  of  a  calculus  or 
the  relations  of  a  dilatation  may  be  overlooked. 

In  the  case  of  a  death  from  general  infection  following  a  minor  operation  in 
which  the  starting  point  of  the  infection  is  not  clear  it  is  advisable  to  examme 
every  part  of  the  field  of  operation  for  the  primary  seat  of  the  morbid  process. 
A  single  minute  stitch  abscess  deep  down  in  the  perineal  tissues  may,  under 
certain  conditions  of  lowered  vitality,  be  sufficient  to  account  for  the  existence 
of  huge  multiple  pyemic  abscesses  in  various  regious  of  the  body. 

Where  there  are  no  local  evidences  of  infection,  and  the  patient  during  life 
has  nevertheless  shown  suspicious  clinical  symptoms  of  it,  the  heart  blood 
should  be  examined  for  bacteria  in  coverslip  preparations  and  by  means  of  cul- 
tures. Lesions  resulting  from  a  terminal  local  infection,  especially  those  occur- 
ring after  operations,  are  found  not  infrequently  in  the  intestinal  mucous 
membrane. 

In  every  instance  the  gat  should  be  cut  up  along  its  whole  length  and 
closely  examined,  first  without  being  washed,  and  next  after  a  thorough  cleans- 
ing of  the  mucous  surface.  If  this  be  done  as  a  matter  of  routine,  one  can 
scarcely  overlook  a  terminal  enteritis,  nor  the  intestinal  lesions  of  corrosive  sub- 
limate poisoning,  a  fatality  for  which  the  gynecologist  and  obstetrician  are 
unfortunately  occasionally  responsible. 

How  to  close  up  a  Body . — Medical  men  can  do  much  to  dissipate 
the  general  prejudice  of  the  laity  against  post-mortem  examinations  by  making 
the  procedure  as  little  objectionable  as  possible.  With  care  a  complete  au- 
topsy can  be  conducted  and  the  body  restored  to  the  friends  without  the  slight- 
est evidence  of  disturbances.  Some  forethought  as  to  the  location  of  the  sev- 
eral incisions,  and  a  little  extra  care  and  attention  in  the  drying  of  the  cavities 
and  in  the  final  sewing  up  and  cleansing,  are  all  that  is  necessarj^  A  body 
should  never  be  closed  up  with  large  quantities  of  fluids  remaining  in  the  cavi- 
ties, but  these  should  be  thoroughly  dried  and  filled  with  sawdust  or  cotton 
waste.  If  there  is  any  tendency  to  putrefaction,  the  addition  of  a  small  quantity 
of  some  disinfectant,  such  as  sublimate  or  carbolate  of  lime,  will  be  of  service. 

Description  of  the  Findings. — An  accurate  description  of  the 
findings  at  each  autopsy  should  be  dictated,  if  possible,  while  the  procedure  is 
in  progress,  or  at  any  rate  immediately  afterward,  while  the  details  are  still 
fresh  in  the  mind  of  the  examiner,  and  the  record  should  l)e  kept  for  future 
reference. 

The  anatomical  diagnosis  can  be  confirmed  and  afterward  added  to  by  means 
of  a  microscopic  examination  of  the  frozen  sections  of  the  fresh  tissue,  and  of 
sections  cut  and  stained  after  fixing  and  hardening.  It  should  be  finally  com- 
pleted by  a  consideration  of  the  results  of  the  bacteriological  examination. 

If  the  mechanical  part  of  a  carefully  conducted  autopsy  is  difficult,  the  de- 
scription of  the  organs  is  even  more  so.     To  be  of  value,  the  statements  must  be 


THE    PKESERVATIOX    OF   TISSUES    FOR   MICROSCOPIC    EXAMINATIOIf.  537 

precise  and  comprehensive  without  being  diffuse.  Instead  of  crude  guesses  at 
sizes,  weights,  and  measures,  the  quantities  should  be  accurately  determined  with 
rule,  scales,  or  graduated  vessels.  The  clinical  statistician  knows  full  well  the 
uselessness  of  the  majority  of  the  autopsy  protocols.  Statistics  at  best  are  preca- 
rious structures  to  build  upon,  but  when  they  have  been  compiled  from  slovenly 
and  inaccurate  records  they  can  not  fail  to  be  misleading.  On  the  other  hand, 
a  series  of  exact,  complete,  objective  descriptions  of  autopsies  on  gynecological 
<;ases  affords  statistics  which,  when  properly  compiled  and  studied,  yield  deduc- 
tions to  the  pi'actical  surgeon  of  very  considerable  value.  The  three  protocols 
which  are  appended  have  been  selected  at  random,  and  afford  examples  of  autop- 
sies on  patients   dying  both  without  operation  and  after  operation. 

The  Preservation  of  Tissues  for  Microscopic  Examination. — F  ixing  Agents, 
— It  is  often  necessary  for  the  practicing  surgeon  to  submit  to  a  pathologist  for 
examination  and  diagnosis  fragments  or  masses  of  tissue  removed  at  operation 
or  at  autopsy.  In  order  that  the  tissues  may  reach  the  microscopist  in  good 
condition  it  is  essential  that  they  shall  be  placed  soon  after  excision — the 
•earlier  the  better — in  a  fixmg  solution  ;  that  is,  one  that  will  kill  the  tissue  cells 
and  retain  the  structures  in  a  condition  as  little  removed  as  possible  from  that 
under  which  they  existed  in  the  living  body. 

Uterine  scrapings  and  bits  of  tumors,  well  fixed  and  hardened,  when  exam- 
ined by  a  competent  pathologist,  frequently  throw  light  on  obscure  cases  which 
clinical  methods  have  failed  to  explain.  It  has  been  objected  that  when  the 
clinician  is  in  doubt  the  pathological  report  often  fails  to  decide  as  to  the  nature 
of  the  condition.  But  while  this  can  not  be  denied,  it  is  also  true  that  the  patho- 
logical examination  in  many  instances  is  absolutely  positive,  and  not  infrequently 
leads  to  the  discovery  of  a  state  of  affairs  entirely  unsusj^ected  before  by  the 
surgeon.  The  logic  which  demands  that  because  they  are  not  always  decisive 
the  examination  of  the  pathologist  shall  be  entirely  dispensed  with,  is  not  unlike 
the  logic  of  many  debtors,  who,  because  they  can  not  meet  all  their  liabilities, 
prefer  to  pay  no  debt  rather  than  to  use  the  means  they  possess  in  order  to  dis- 
charge some  of  them. 

Most  valuable  specimens  are  repeatedly  ruined  by  surgeons  through  a  want 
of  knowledge  of  the  (pialities  requisite  for  a  good  preserving  fluid.  Thus  it  is 
not  uncommon  for  the  pathologist  to  receive  tissues  which  have  l)een  thrown 
into  a  small  quantity  of  weak  alcohol  or  into  a  dilute  solution  of  carbolic  acid, 
where  in  the  course  of  a  short  time  they  are  macerated  and  rendered  unfit  for 
thorough  and  satisfactory  examination,  if  indeed  they  be  not  entirely  ruined. 

If  the  ])athologist  is  easily  accessil)le,  he  will  always  prefer  to  receive  the 
specimen  innnediately  after  removal  from  the  body,  before  the  tissues  have  been 
acted  u])on  by  any  reagents.  He  can  then  study  the  fresh  tissues  in  teased 
preparations  or  in  fro/en  sections,  and  finally  choose  for  himself  the  fixing  fiuid 
which  experience  has  taught  him  to  be  best  adapted  to  the  particuliu-  tissue  in 
question.  It  is  coni])aratively  seldom,  however,  that  circumstances  will  permit 
of  this  immediate  delivery  of  tissues,  and  the  surgeon  is  compelled  to  choose  for 
himself  a  fixinor  a<j:ent. 


538  ON   THE    CONDUCT   OF   AUTOPSIES. 

The  fixing  agent  which  for  general  use  may  be  recommended  to  the 
surgeon  as  safest  and  least  likely  to  lead  to  injury  of  the  tissues  is  strong  alcohol. 
It  has  many  advantages,  in  that  it  is  easily  accessible,  acts  quickly,  and  permits 
of  the  preservation  of  comparatively  large  specimens.  Whereas  with  the  liner 
fixino;  asents  the  size  of  the  individual  bits  of  tissue  sliould  not  exceed  from  1 
to  2  millimeters  square,  with  strong  alcohol  pieces  of  from  1  to  2  centimeters 
square  will  usually  harden  well.  Indeed,  large  masses  of  tissue,  provided  they 
be  cut  open  at  intervals  of  from  1  to  2  centimeters,  may  be  hardened  in  alcohol 
quite  well,  provided  the  amount  of  fluid  employed  be  proportionately  large.  A 
specimen,  small  or  large,  preserved  in  alcohol  requires  at  least  from  ten  ta 
twenty  times  its  bulk  of  fluid,  and  the  alcohol  should  be  changed  once  or  twice 
at  intervals  of  twenty-four  hours. 

A  second  hardening  solution,  the  materials  for  which  can  be 
obtained  at  any  druggist's,  is  the  well-known  Miiller's  fluid,  which 
consists  of  two  and  a  half  parts  of  bichromate  of  potassium  and  one  part  of 
sulphate  of  sodium  dissolved  in  one  hundred  parts  of  water.  Large  pieces  of 
tissue — for  example,  the  genital  organs  en  masse — can  be  safely  hardened  in  this 
fluid,  provided  that  certain  precautions  are  taken.  The  uterus  must  be  laid  open 
and  the  mass  of  tissue  so  suspended  in  a  large  jar  of  the  fluid  that  as  much  sur- 
face as  possible  may  be  exposed  to  the  action  of  the  hardening  reagent.  The 
fluid  should  be  changed  every  day  during  the  first  week,  afterward  every  three 
days  until  the  hardening  is  complete.  The  process  takes  from  six  to  eight  weeks 
at  the  temperature  of  a  living  room,  or  from  two  to  four  weeks  in  a  thermostat 
at  37°  C.  (98*5°  F.).  In  warm  weather  the  addition  of  a  few  fragments  of  gum 
camphor  to  the  fluid  prevents  the  growth  of  fungi.  On  account  of  the  frequent 
changing  of  the  fluid  which  is  necessary,  Miiller's  fluid  is  less  convenient  than 
alcohol  for  ordinary  work. 

Other  Methods  of  Fixing . — The  preparation  and  methods  of  use 
of  solutions  used  in  finer  histological  work  need  not  now  be  considered.  The 
formulas  and  application  of  Fleming's  solution  and  Hermann's  fluid  are  de- 
scribed in  the  text-books  of  microscopic  technique.  Two  methods  may  perhaps 
be  mentioned  here  : 

1.  The  method  of  fixing  with  corrosive  sublimate,  which  is  popular  with  some 
surgeons,  and,  indeed,  when  successfully  carried  out,  yields  excellent  results,  and 

2.  The  method  of  fixing  with  formalin. 

In  employing  the  former  small  bits  of  tissue,  not  exceeding  0-5  centimeters 
(2  inches)  square,  are  immersed  immediately  after  removal  from  the  l)ody  in  a 
saturated  solution  of  corrosive  sublimate  in  physiological  salt  solution  (0-0  per 
cent  sodium  chloride  in  distilled  water).  The  tissue  remains  in  the  fixing  fluid 
from  one  to  twenty -four  hours ;  it  is  then  hardened  in  a  series  of  alcohols  of 
gradually  increasing  strength  (33^,  50,  GO,  YO,  80,  95  per  cent). 

The  second  method  is  of  comparatively  recent  date.  The  formalin  of  com- 
merce consists  of  an  aqueous  solution  of  formaldehyde.  As  a  fixing  agent  for 
histological  purposes  it  has  been  found  convenient  to  use  a  mixture  of  ten  parts 
of  this  commercial  liquid  with  ninety  parts  of  water.     The  pieces  of  tissue 


DEATH    WITHOUT    OPERATIOX.  539 

should  be  small  and  should  remain  in  the  fluid  only  for  from  twelve  to  twenty- 
four  hours,  after  which  they  are  further  hardened  in  alcohol. 

By  the  use  of  this  method  the  blood  and  tissue  cells  are  well  preserved  and 
the  specimen  is,  as  a  rule,  of  excellent  consistence  for  cutting. 

Death  without  Operation. — In  order  to  illustrate  the  foregoing  remarks  three 
protocols  of  autopsies  are  appended,  taken  from  the  records  of  the  Pathological 
Laboratory  of  the  Johns  Hopkins  Hospital  and  University. 

Protocol  I. — Case  dying  without  operation. 

Feb.  1, 1890.     J.  J.,  Path.  No.  7T  (colored),  housewife,  aged  about  forty-iive. 

Anatomical  Diagnosis.  —  Myoma  of  uterus  with  central 
necrosis,  dilatation  of  ureters  from  pressure,  pyelone- 
phritis, chronic  passive  congestion  and  emphysema  of 
lungs,  displacement  of  viscera  and  deformity  of  thorax  in 
consequence  of  tumor.  General  marasmus.  Heart  hyper- 
trophy with  hyaline,   calcific,  and  fatty  degeneration. 

Exterior. — Body,  150  centimeters  (5  feet)  in  length;  emaciated;  rigo?' 
mortis  present.  Deep  depression  beneath  each  clavicle,  more  marked  on  the 
right  side  ;  mammae  atrophic  ;  the  manubrium  sunken  ;  a  slight  elevation  corre- 
sponding with  the  articulation  of  the  second  rib  and  sternum,  more  marked  on 
the  right  than  on  the  left  side.  Abdomen  enormously  distended  ;  a  firm  tumor 
mass  felt  beneath  the  thin  abdominal  wall,  projecting  more  on  the  right.  The 
right  buttock,  on  which  the  weight  of  the  body  has  evidently  rested,  is  smaller 
than  the  left.  The  tumor  feels  firm  and  smooth,  except  directly  above  the 
pubes,  where  a  hard,  slightly  movable  mass  can  be  felt. 

Measurements  :  From  tlie  tip  of  the  ensiform  cartilage  to  symphysis  j)ubis, 
40  centimeters;  umbilicus  displaced  to  the.  right  5  centimeters;  greatest  ab- 
dominal circumference,  T9'5  centimeters  ;  thoracic,  69  centimeters.  In  the  skin 
over  tumor  on  the  right  side,  4  centimeters  below  and  0  centimeters  to  the 
right  of  the  umbilicus,  there  is  a  round  smooth  cicatrix  2"5  centimeters  in 
diameter  ;  on  the  posterior  surface  of  lower  extremities  several  large,  irregular, 
circumscribed  ecchymoses. 

Subcutaneous  fat  slightly  developed,  muscles  pale.  Diaphragm  on  right 
side  in  upper  portion  of  second  intercostal  space,  on  left  at  the  middle  of  third 
rib  ;  the  second  intercostal  space  on  each  side  3  centimeters,  the  first  2*5  centi- 
meters, wide  ;  the  articulation  of  the  second  rib  with  the  sternum,  on  the  right 
side  with  the  body  in  the  dorsal  position,  ahnost  directly  over  the  articulation 
of  the  first,  only  1  centimeter  below  a  perpendicular  line  from  the  lower  por- 
tion of  the  first  rib  ;  on  the  left  side  this  is  not  so  pronounced.  The  deep  cer- 
vical veins,  particularly  those  on  the  right  side,  mi^re  dilated  and  engorged  ; 
right  jugular  2*25  centimeters  in  diameter. 

Peritoneal  Cavity . — On  opening  the  peritoneal  cavity  a  large  smooth 
tumor  mass  appears  immediately  adjacent  to  the  a])donnnal  walls,  its  surface 
covered  with  large  tortuous  veins  with  firm  adhesions  over  a  small  area  of  tumor 
surface,  corresponding  to  the  cicatrix  in  the  abdominal  walls,  those  adhesions 
arranged  in  a  more  or  less  crescentic  shape  ;  the  largest  of  them,  ('.  centimeters 


54:0  ON"   THE    CONDUCT    OF   AUTOPSIES. 

in  length,  is  easily  broken  through.  In  the  middle  line  of  the  tumor  mass  is  a 
white,  firm,  movable  nodule,  and  similar  nodules  are  present  on  its  upper  left 
side.  The  extreme  superior  margin  of  the  tumor  corresponds  to  a  line  drawn 
across  from  the  ends  of  the  eighth  pair  of  ribs.  On  the  anterior  surface  of 
the  tumor  is  a  dark-colored  fattened  body,  partly  covered  over  with  a  thin 
meml)rane,  the  upper  edge  of  which  is  thickened  ;  on  the  right  side  and  lower 
down  a  similar  body  is  visible  ;  closer  examination  shows  these  bodies  to  be  en- 
larged and  flattened  ovaries,  covered  over  in  part  by  the  broad  ligaments ;  the 
right  ovary  is  connected  with  the  adhesions  previously  described  ;  the  left  ovary 
and  both  uterine  tubes  and  fimbriae  are  free  from  adhesions. 

The  veins  in  both  broad  ligaments,  especially  those  in  the  right,  are  enor- 
mously distended.  The  growth  occupies  almost  all  of  the  abdominal  cavity  ;  all 
of  the  small  intestines  and  the  greater  part  of  the  colon  lie  above  the  tumor. 
The  peritoneum  is  smooth  ;  the  cecum  is  displaced  upward  and  lies  against  the 
gall  bladder  ;  the  lower  portion  of  the  ileum  descends  beneath  the  tumor,  then 
turns  upward  to  be  inserted  into  the  cecum. 

All  of  the  lymphatic  vessels  in  the  lower  portion  of  the  abdomen  enormously 
dilated  and  filled  with  clear,  slightly  yellowish  contents  ;  some  of  the  post-mes- 
enteric  lymph  vessels  measure  5  millimeters  in  diameter ;  large  dilated  lym- 
phatics can  be  seen  along  the  ureters  and  over  the  capsule  of  the  kidney  ;  mes- 
enteric and  retroperitoneal  lym])hatic  glands  small. 

Thoracic  Cavity . — The  lower  border  of  liver  corresponds  to  tip  of 
ensiform  cartilage  in  median  line,  elsewhere  to  lower  border  of  the  fifth  rib  ; 
the  lower  border  of  descending  innominate  veins  is  ^  centimeter  above  the 
sterno-clavicular  articulations.  Right  lung  is  bound  down  by  tolerably  firm 
adhesions  ;  the  left  is  free  ;  both  pleural  cavities  are  dry. 

Heart . — Both  layers  of  pericardium  smooth  ;  in  pericardial  cavity  a  few 
cubic  centimeters  of  clear  serous  fluid ;  in  both  sides  of  heart  fluid  blood  and 
fresh  coagula ;  left  ventricle  slightly  contracted  ;  no  valvular  distortion  ;  heart's 
flesh  tolerably  flrm,  of  a  dark-brownish  color.  In  the  wall  of  the  left  ventricle, 
in  most  cases  just  beneath  the  endocardium,  are  numerous  small  yellowish  foci. 
Tliickness  of  left  ventricle,  lY  millimeters  ;  of  right,  4  millimeters  ;  length  of 
left  ventricle  to  lower  l)order  of  aortic  valve,  8  centimeters.  Endocardium  j^re- 
sents  a  few  pale  patches.  Aorta  just  above  valves  measures  62  millimeters  in 
circumference.  The  entrance  to  the  left  coronary  artery  is  slightly  dilated. 
"Weight  of  heart,  260  grammes. 

Lungs. — Left  lung  small,  anterior  border  thin  and  emphysematous,  surface 
smooth  ;  in  the  bronchial  artery  fresh  clots  ;  veins  normal ;  bronchi  slightly 
dilated  ;  mucous  membrane  pale.  Posterior  and  lower  portion  of  lung  firm  and 
dense.  Right  lung  arteries  contained  fresh  clots,  veins  free  ;  bronchi  through- 
out lung  much  dilated ;  surface  of  lung  smooth,  save  for  old  adhesions  ;  anterior 
edge  pale,  emphysematous  ;  posterior  and  lower  portions  firm  and  dense  in 
structure,  congested. 

Liver. — Gall  duct  open;  liver  small  ;  dimensions,  25  x  14  X  6*5  centi- 
meters ;   surface  mottled  ;  on  section  also  mottled,  with  numerous  very  pale 


DEATH    WITHOUT   OPERATION.  541 

areas  ;  otherwise  smootli  and  congested.  Gall  bladder  contains  about  25  cubic 
centimeters  of  clear,  transparent,  yellowish  bile.     Weight,  1,520  grammes. 

Spleen . — Spleen  measures  10  x  7  3'5  centimeters  ;  capsule  smooth  ;  on 
section  of  a  firm  dark-brownish  color  ;  trabeculae  visible.    Weight,  110  grammes. 

Stomach,  intestines,  pancreas,  and  suprarenal  capsules  normal. 

Kidneys. — Left  kidnej,  17  X  t  X  5-5  centimeters;  pelvis  dilated.  (Pel- 
vis of  both  kidneys  turned  to  front.)  Capsule  adherent,  surface  irregular  and 
lobulated  ;  beneath  capsule  numerous  whitish  foci  ;  on  section,  throughout  kid- 
ney numerous  purulent  foci,  following  lines  running  from  pelvis  toward  cortex  ; 
the  pyramids  flattened,  pelvis  generally  smooth,  here  and  there  covered  with  a 
fibro-purulent  exudation.  Ureters  dilated,  firmly  adherent  to  the  posterior  sur- 
face of  the  tumor.  The  dilatation  extends  only  from  the  point  where  the  ureter 
separates  from  the  tumor. 

Eight  kidney,  17  X  6  X  4-5  centimeters  ;  dilated.  Kidney  filled  with  pu- 
rulent foci ;  in  general,  shows  the  same  condition  as  left  kidney ;  the  ureter  is 
adherent  to  tumor  for  a  longer  distance  and  the  dilated  jjortion  is  longer  than 
that  on  the  left  side. 

Uterus  and  Appendages . — The  uterus,  19  centimeters  in  length,  is 
thin,  anteflexed,  and  extends  directly  over  the  anterior  surface  of  tumor.  Both 
Fallopian  tubes  patent  until  they  reach  the  tumor,  when  they  become  lost  in  the 
tumor  substance  ;  the  right  tube  can  be  traced  almost  into  uterus.  Both  ova- 
ries flattened,  the  right  6-5  X  3*5  X  0*5  centimeters,  the  left  5  X  4  X  0*75  cen- 
timeters. In  the  left  ovary  a  large  corpus  luteum,  with  a  dark-brownish  clot 
3  centimeters  in  diameter. 

Bladder . — Bladder  contracted  ;  contains  small  amount  of  milky  purulent 
urine  ;  mucous  membrane  ecchymosed  and  of  a  dark-red  color. 

T  u  m  o  r . — The  tumor  is  a  large,  firm  mass,  on  its  posterior  surface  divided 
into  two  distinct  lobes  by  deep  depression  corresponding  to  vertebme.  The 
small  tumor,  on  anterior  aspect,  which  was  felt  previously,  was  found  to  be  sep- 
arated from  the  rest  and  growing  into  the  uterus.  Tumor,  on  section,  dense, 
firm,  its  center  occupied  by  a  large  triangular  cavity,  the  longest  diameter  of 
which  is  17  centimeters,  at  base  11  centimeters;  this  cavity  is  filled  with  clear, 
sliglitly  blood-stained  fluid,  and  with  dense  masses  of  yellowish-white,  hard, 
elastic  tissue.  The  greatest  diameter  of  tumor  is  25  centimeters.  The  small 
tumor  on  anterior  surface  dense,  firm,  and  somewhat  opaque. 

Microscopic  Examination . — Myocardium  ;  left  ventricle  shows  in 
frozen  section  numerous  smaller  and  larger  opaque  foci ;  in  the  center  of  these 
are  small  darker  masses  of  irregular  shape.  Some  of  these  patches  measure  1  to 
2  millimeters  in  diameter  ;  others  are  very  minute  ;  the  dark  patches  correspond 
to  fatty  degeneration  of  the  muscle  fil»ers;  among  these  are  numerous  fibers 
which  have  a  refractive  homogcMieous  appearance. 

The  fatty  degeneration  is  chiefly  in  and  arouiul  the  foci  containing  hyaline 
fibers,  but  in  places  it  appears  to  exist  independently  of  them  ;  on  the  other 
hand,  foci  of  hyaline  fibers  or  single  hyaline  fibers  occur  with  only  a  few  fatty 
fibers  observable  in  their  neighborhood.     The  refractive  material  dissolves  in 


54:2  ox   THE    COXDUCT   OF   AUTOPSIES. 

glacial  acetic  acid  rather  slowlj,  rapidly  in  HCl  and  IliS'Og  without  ebulhtion  of 
gas.  As  it  dissolves,  the  fibers  containing  it  swell  up  and  lose  their  highly 
refractive  appearance  and  look  hyaline.  The  refractive  material  is  insoluble  in 
strong  caustic  potash  or  annnonia.  On  the  addition  of  H^SO^  the  refractive 
substance  is  replaced  by  masses  of  crystals  or  sulphate  of  lime.  The  refractive 
material  therefore  is  impregnated  with  a  lime  salt  which  is  not  the  carbonate.  The 
refractive  fibers  are  brittle  and  show  sharp  contours ;  they  break  in  sharp  lines. 
One  of  these  was  noticed  in  the  right  ventricle,  wdiich  was  examined  in  six  differ- 
ent places.  None  found  in  left  auricle  (examined  in  two  places).  Found  in  all 
parts  of  left  ventricle,  but  appear  to  be  most  abundant  in  upper  part  near  left 
border.  Stained  fresh  section  showed  a  marked  increase  of  nuclei  in  and  around 
the  clumps  of  hyaline  fibers,  which  are  themselves  devoid  of  nuclei,  and  often 
seem  broken  up.  The  fatty,  calcified  foci  appear  to  be  most  numerous  and  ex- 
tensive in  that  part  of  the  myocardium  which  is  near  the  pericardium,  but  they 
are  to  be  found  also  near  the  endocardium.  Sections  placed  in  Fleming's  solu- 
tion show  well  the  fatty  degeneration  which  is  present  around  all  calcified  fibers, 
but  these  fibers  themselves  contain  no  fatty  particles. 

On  microscopical  examination  the  tumor  is  found  to  be  a  leiomyoma. 

Death  Six  Days  after  Operation. — Protocol  II. — Case  of  death,  Jan.  27,  1893, 
six  days  after  operation  (Jan.  21,  1893).  (Abdominal  Section,)  M.  E.  A.,  aged 
twenty -nine,  1763. 

Anatomical  Diagnosis . — G eneral  peritonitis;  stitch  ab- 
scesses; syphilitic  deformity  of  the  liver;  gummata  in 
liver;  congestion  of  lungs;  chronic  diffuse  nephritis; 
amyloid   infiltration   of  kidney,    liver,    and   spleen. 

In  the  median  line  of  the  abdomen  is  a  linear  incision  10  centimeters  (4 
inches)  long.  The  lower  3*5  centimeters  (1|-  inch)  of  this  gapes  ;  on  removing 
the  stitches  they  are  found  to  be  covered  with  pus.  Pus  can  also  be  squeezed 
from  the  stitch  holes.  The  nniscle,  where  exposed,  is  covered  with  pas,  and  at 
the  superior  angle  of  the  wound,  where  the  muscular  layers  are  separated  from 
one  another,  is  a  small  cavity  containing  pus.  The  omentum  contains  a  con- 
siderable quantity  of  fat,  is  injected,  and  adherent  by  its  outer  surface  to  the 
abdominal  wound  ;  on  its  inner  surface  %vithin  the  pelvis  it  is  adherent  to  the 
intestines.  Its  under  surface  over  the  lower  thii*d  of  its  extent  is  intensely 
injected,  edematous,  and  cloudy  from  the  presence  of  pus.  Along  its  inferior 
border  it  is  much  swollen  and  covered  Avith  a  fibrino-purulent  exudate.  There 
are  dense  masses  of  fibrin  between  the  coils  of  intestines  in  the  pelvis  and  also 
on  the  parietal  peritoneum  corresponding  to  them.  The  large  intestine  occu- 
pies the  inferior  portion  of  the  pelvis,  and  its  coils  are  more  firmly  adherent 
than  are  those  of  the  small  intestine.  Over  the  peritoneal  surface  of  the  intes- 
tines in  general  a  very  delicate  deposit  of  fibrin  can  be  made  out.  About 
20  centimeters  (8  inches)  above  the  ileo-cecal  valve  a  loop  of  intestine  12 
centimeters  (5  inches)  in  length  is  folded  upon  itself  and  covered  with  a 
thick  fibrinous  deposit  which  can  be  readily  stripped  off.  This  deposit  com- 
mences  at  the   mesenteric   border  of   the  gut  and  extends  two  thirds  of  the 


DEATH    SIX    DATS    AFTER    OPERATION".  543 

way  around  it.     The  peritoneal  surface  beneath  the  fibrin  is  deeply  injected 
and  roughened. 

The  peritoneal  coat  of  the  lower  portion  of  the  descending  colon  is  intensely 
injected  and  covered  with  hemorrhagic  masses  of  fibrin.  The  gut  is  everywhere 
considerably  distended  and  contains  fiuid  yellow  feces.  The  mucous  membrane 
of  the  small  intestine  is  somewhat  injected  ;  opposite  the  loop  above  mentioned 
the  injection  is  especially  marked.  The  mucosa  of  the  large  intestine,  except 
that  of  the  rectum,  which  is  congested,  is  pale.  The  apj)endix  is  bound  down  at 
its  middle  by  old  adhesions,  but  is  otherwise  normal. 

Both  uterine  appendages  are  missing,  being  represented  by  stumps  on  either 
side  of  the  uterus.  These  stumps  are  covered  with  hemorrhagic  masses  of  fibrin 
and  on  section  are  seen  to  be  suiiused  with  blood.  The  cul-de-sac  between  the 
uterus  and  the  bladder  is  lined  with  a  thin  layer  of  fibrin  and  there  are  here 
some  old  adhesions.  On  the  superior  surface  of  the  uterus  and  between  the  pos- 
terior surface  of  the  uterus  and  the  anterior  surface  of  the  rectum  similai:  old 
adhesions  exist.  The  peritoneum  in  Douglas's  pouch  is  also  covered  with  fibrin. 
The  cavity  of  the  uterus  is  normal.  The  bladder  is  normal.  The  mucous  mem- 
brane of  the  stomach  is  pale,  except  in  a  few  areas  where  it  is  congested. 

Liver , — The  liver  weighs  1,600  grammes.  Size  25  X  17  X  9*5  centimeters. 
It  is  adherent  to  the  abdominal  wall  and  to  the  diai^hragm,  and  there  are  large 
elevated  areas  with  corresponding  depressions,  which  give  the  organ  a  lobulated 
appearance. 

The  gall  bladder  is  thickened  and  is  bound  down  by  old  adhesions. 

The  liver  on  section  is  mottled,  congested  areas  alternating  with  pale  yellow 
opaque  areas.  Bands  of  dense  white  tissue  run  between  the  lobulations,  and  the 
portal  veins  appear  to  be  dilated.  Scattered  throughout  the  liver  are  many 
minute  gray  translucent  and  yellow  foci,  the  largest  being  2  millimeters  in 
diameter. 

Kidneys, — Combined  weight  340  grammes.  Both  are  alike;  size 
12  X  0"5  X  4  centimeters ;  capsule  strips  off  readily.  The  surface  is  slightly 
irregular,  presenting  depressed  atrophic  areas.  The  veins  beneath  the  capsule 
are  injected ;  on  section  the  pyramids  are  seen  to  be  injected.  The  cortex  aver- 
ages 8  millimeters  in  thickness  and  is  pale.  The  striae  are  in  part  obliterated ; 
where  present  they  are  very  fine.  The  Malpighian  bodies  are  prominent  and 
red.     The  whole  organ  is  edematous. 

L  u  n  g  s  . — Both  lungs  are  alike  ;  they  retract  on  opening  the  thorax  ;  they 
are  slightly  emphysematous  at  their  margins ;  elsewhere  they  are  deeply  in- 
jected. The  pleurae  are  cyanotic.  The  bronchi  are  much  injected  and  contain  a 
small  amount  of  tenacious  mucus.  The  blood  vessels  of  the  lung  are  normal. 
The  bronchial  glands  are  deeply  pigmented  and  edematous. 

The  heart  weighs  220  grammes  and  is  apparently  nornuil. 

The  spleen  measures  18-5  X  8  X  3  centimeters.  The  ca})8ule  is  adherent  in 
a  few  places  and  the  organ  is  firmer  than  normal.  On  section  the  trabecula? 
are  visible ;  but  few  Malpighian  bodies  are  visible  to  the  naked  eye.  The  pan- 
creas is  apparently  normal.     The  mesenteric  glands  are  swollen  and  congested. 


544  ON   THE    CONDUCT   OF    AUTOPSIES. 

Microscopic  Examination  of  Frozen  Sections . — The  liver 
tissue  is  divided  up  into  areas  of  one  or  of  several  lobules  and  occasionally  into 
fractions  of  a  lobule  by  dense  masses  of  connective  tissue.  The  liver  cells  are 
granular,  swollen,  and  often  fatty.  Circumscribed  areas  of  necrosis  of  variable 
size  are  found ;  these  correspond  to  the  minute  foci  visible  to  the  naked  eye.  In 
some  places  these  areas  are  surrounded  by  a  zone  of  fatty  cells,  but  are  without 
a  connective  tissue  capsule ;  about  others  there  is  a  distinct  zone  of  connective 
tissue.  Scattered  throughout  the  liver  numerous  small  masses  of  necrotic  cells 
can  be  made  out.  The  capillaries  running  between  these  contain  a  good  many 
polynuclear  leucocytes.  The  dense  bands  of  connective  tissue  which  are  scat- 
tered throughout  the  liver  are  often  rich  in  blood  vessels,  the  walls  of  which 
present  a  hyaline,  glistening  appearance.  Stained  with  Lugol's  solution,  this 
glistening  material  gives  the  characteristic  amyloid  reaction. 

Kidneys . — The  vessels  in  the  pyramids  and  in  some  of  the  glomerular 
capillaries  yield  the  characteristic  amyloid  reaction.  There  is  an  increase  of  con- 
nective tissue  between  the  tubules,  and  in  foci  the  capsules  of  Bowman  are 
thickened.     Hyaline  casts  are  present  in  some  of  the  tubules. 

Bacteriological  Examination.  —  Smear  coverslip  preparations 
from  peritoneum  and  kidney  substance  were  negative,  but  tubes  of  nutrient 
agar-agar  inoculated  with  the  exudate  on  the  peritoneum  gave  a  pure  culture  of 
the  staphylococcus  pyogenes  aureus.  The  same  organism  was 
found  in  the  subcutaneous  portion  of  the  abdominal  wound,  in  a  catgut  ligature 
from  the  deep  part  of  the  abdominal  wound,  and  from  the  omentum  just  beneath 
the  abdominal  incision. 

One  and  five  tenths  of  a  cubic  centimeter  of  a  forty-eight-hour  bouillon  cul- 
ture of  this  staphylococcus  introduced  into  the  aural  vein  of  a  rabbit 
caused  the  death  of  the  animal  at  the  end  of  five  days. 

The  lung  contained  a  short  bacillus  with  rounded  ends,  about  half  as  long 
again  as  broad.  On  cultivation  on  agar-agar,  gelatin,  acid  gelatin,  potato,  and 
in  litmus  milk,  it  closely  resembled  the  bacillus  c  o  1  i  communis,  but 
was  not  positively  identified.  Culture  tubes  inoculated  from  the  kidney,  spleen, 
and  liver  remained  sterile. 

Death  Fifty-one  Days  after  a  Minor  Operation. — Protocol  III. — A  case  in 
which  the  symptoms  of  infection  due  to  a  minor  operation  became  manifest 
only  after  the  lapse  of  six  weeks'  time,  when  the  external  wound  was  healed. 

Abstract  of  Clinical  History . — M.  H.  (1805),  colored,  aged  fifty- 
eight  ;  previously  healthy ;  the  mother  of  ten  children  ;  catamenia  always  regu- 
lar. The  present  trouble  began  about  three  years  before  admission,  when  the 
patient  noticed  a  protrusion  between  the  external  genitals,  slowly  increasing  in 
size.  It  was  at  first  painful  to  the  touch,  l)ut  could  be  kept  up  by  wearing  a 
bandage.  She  had  had  constant  pains  in  the  back  and  had  to  rise  five  or  six 
times  during  the  night  t(j  urinate.     Her  bowels  were  regular. 

She  was  examined  Jan.  26,  1893,  by  Dr.  Kelly,  and  considered  too  feeble  for 
operation.  She  improved,  however,  and  on  Feb.  7,  1893,  the  resident  physician 
operated   for  prolapse,  performing  perineorrhaphy  and  removing  the  cervix. 


DEATH    FIFTY-OXE    DAYS   AFTER   A    MIXOR   OPERATIOX.  545 

She  did  well  until  March  22d,  when  she  was  first  noticed  to  have  peculiar 
twitching  movements.  Eespiration  was  difiicult,  and  there  was  slight  nausea  but 
no  headache.  Examination  of  the  urine  at  this  time  showed  a  large  amount  of 
albumin  and  hyaline,  granular,  and  blood  casts.  For  two  days  she  improved, 
but  died  on  March  30th. 

Autopsy  (Dr.  L.  F.  Barker)  nine  hours  after  death. 

Anatomical  Diagnosis . — Eecent  operation  on  cervix  and  perineum  ; 
local  infection  of  deep  perineal  tissues  ;  secondary  general  infection,  with  staph- 
ylococcus pyogenes  aureus,  miliary  abscesses  in  heart  muscle,  kidneys, 
and  intestines  ;  arterio-sclerosis ;  chronic  passive  congestion  ;  pulmonary  edema ; 
pulmonary  emphysema ;  pneumoconiosis ;  infarction  of  spleen  ;  acute  sjjlenic 
tumor;  chronic  diffuse  nephritis;  acute  nephritis;  ovarian  cystomata;  cyst  of 
broad  ligament ;  fibrous  atrophy  of  the  ovaries ;  cholelithiasis. 

Exterior . — Body  151  centimeters  long.  Rigor  mortis  partial  in  upper 
extremities,  complete  in  lower.  Body  well  nourished.  'No  edema  of  the 
ankles.  Diaphragm  on  right  side  at  fifth  interspace ;  left  side,  at  sixth  rib. 
Peritoneal  cavity  dry.  Omental  fat  abundant.  Liver  margin  4  centimeters 
below  free  border  of  ribs.  Spleen  does  not  pass  costal  margin.  Cartilages 
of  ribs  somewhat  calcified.  Beneath  visceral  layer  of  pericardium,  over  surface 
of  left  ventricle,  3  centimeters  from  base,  is  a  minute  grayish- white  opaque  area 
1^  millimeter  in  diameter  which  extends  2  millimeters  into  the  myocardium. 
The  fat  in  the  epicardium  is  much  increased,  particularly  along  the  interven- 
tricular border. 

The  Heart. — AVeight,  420  granmies;  blood  inside  bright  red.  On  the 
endocardium  of  the  left  ventricle,  in  that  portion  corresponding  to  septum, 
between  the  two  ventricles,  situated  3|-  centimeters  below  root  of  aorta,  is  a 
grayish-yellow  slightly  raised  ojiaque  area  5  millimeters  in  diameter.  Tliis  area 
has  a  tolerably  firm,  somewhat  irregular  base  of  a  dark  bluish-red  color.  It  ex- 
tends a  distance  of  3  millimeters  into  the  myocardium  and  contains  grayish- 
white  pus.  Just  beneath  this  in  the  myocardium  is  another  abscess,  4  milHme- 
ters  in  diameter,  filled  with  grayish-white  pus.  The  rest  of  the  myocardium, 
which  is  fairly  firm  and  red,  shows  several  minute  purulent  foci.  Heart  valves 
normal.  Diffuse,  small,  sclerotic  patches  in  aorta.  Coronary  arteries  dilated  ; 
they  show  also  a  few  sclerotic  patches.  The  right  pleural  cavity  contains  no 
excess  of  fluid.  Some  old  adhesions  over  upper  lobe.  Left  pleural  cavity  free 
from  adhesions. 

The  Lungs. — Surface  of  right  lung  smooth  except  where  old  adhesions 
were  attached.  There  is  a  moderate  amount  of  coal  pigment  marking  ofi*  the 
lobules.  On  section  much  frothy  fluid  escaped,  particularly  from  the  ui)]ier 
lobe.  The  surface  of  the  lung  is  reddish-l)n)wn  in  color  and  not  granular;  the 
upper  lobe  edematous.  The  bronchi  are  filled  with  frothy  fluid  ;  mucous  mem- 
brane congested.  The  right  pulmonary  artery  is  almost  occluded  by  a  large  clot 
of  laminated  fil»rin,  which  is  firmly  adherent  to  one  side  of  the  vessel.  The  in- 
tima  shows  several  small,  yellowish-white  raised  areas.  The  bronchial  glands 
are  deeply  pigmented.     The  left  lung  does  not  differ  materially  from  the  right : 


54G  ON   THE    CONDUCT   OF    AUTOPSIES. 

the  edema  in  it  is  perhaps  not  quite  so  marked.  The  margins  of  both  lungs 
are  rounded  and  show  many  alveoH  dihated  and  filled  with  air. 

The  spleen  weighs  190  grammes ;  dimensions,  12  X  8  X  2^  centimeters. 
The  oro-an  is  generally  a  bright  brownish-red  in  color.  On  its  surface  are  two 
elevated  brownish-red  areas,  one  measuring  4  centimeters  in  diameter.  On  sec- 
tion the  spleen  is  almost  diffluent ;  pulp  abundant ;  Malpighian  bodies  invisible. 
The  dark  brownish-red.  areas  are  wedge-shaped.  One  has  a  soft  center.  The 
color  is  not  uniform,  but  mottled  red  and  brown.  Many  minute  grayish-white 
points  can  be  seen  in  the  pulp. 

The  kidneys  weigh  together  400  grammes.  The  right  measures  15  X  T  X  5 
centimeters.  On  its  free  border  is  a  small  sac  1^  centimeter  in  diameter  filled 
with  clear,  straw-colored  fluid.  Capsule  is  otherwise  smooth  and  can  be  re- 
moved easily.  The  surface  Ijeneath  the  capsule  is  pale  and  shows  very  numer- 
ous single  and  conglomerate  raised  and  yellowish-white  areas,  from  some  of 
which  grayish-white,  gelatinous,  purulent  fluid  exudes.  On  section  the  kid- 
ney is  pale  and  edematous;  average  thickness  of  cortex,  6  millimeters;  fine 
markings  are  obliterated;  strige  are  coarse.  Throughout  cortex  are  numer- 
ous yellowish -white  puriform  areas ;  some  just  beneath  capsule,  others  deeper  in 
its  substance.  There  is  one  wedge-shaped,  slightly  raised  reddish-white  area 
measuring  at  the  base  7  millimeters  beneath  the  capsule.  In  this  area  are  three 
or  four  yellowish-white  foci.  Another  infarction,  measuring  2  centimeters 
at  its  base,  has  miliary  abscesses  about  it.  The  majority  of  the  purulent 
foci  are  in  the  cortex,  but  the  pyramids  contain  many  also.  Sometimes  they 
form  rows  running  halfway  through  the  length  of  the  pyramid  parallel  to  the 
tubes  and  intertubular  vessels.  The  glomeruli  are  pale  and  indistinct.  The 
pelvis  of  the  kidney  is  slightly  congested,  the  pelvic  fat  abundant.  The  left 
kidney  measures  13|^  X  8  X  5^  centimeters,  and  shows  similar  changes  to  those 
in  the  right.     Ureters  and  adrenals  normal. 

The  liver  weighs  1,8(50  grammes;  dimensions,  29  X  18|-  X  T  centimeters. 
Its  surface  is  smooth ;  consistence  fairly  firm.  On  section,  grayish-brown  in 
color,  slightly  mottled.  Lol)ules  indistinct.  The  gall  bladder  is  filled  with  gall 
stones,  thirty-five  in  number,  averaging  in  size  that  of  a  hazelnut.  They  are 
faceted  and  greenish-brown  or  blackish -brown  in  color.  The  bile  is  deep  green- 
ish-brown in  color  and  thick.  The  mucous  membrane  of  the  gall  bladder  is 
normal. 

Pancreas  normal. 

The  stomach  is  large  and  partially  filled  with  fluid.  The  mucous  membrane 
shows  minute  ecchymoses. 

In  the  small  intestine  the  veins  are  dilated,  more  in  some  places  than  in 
others,  and  there  are  occasional  punctiform  ecchymoses  on  the  edges  of  the  folds. 
Throughout  the  jejunum  and  ileum,  particularly  in  the  latter,  for  a  distance  of 
100  centimeters  above  the  ileo-cecal  valve,  there  are  numerous  miliary  and  con- 
glomerate nodules,  which  are  elevated  and  have  often  a  hemorrhagic  border ; 
they  are  usually  opaque  and  grayish-yellow  in  color.  Often  large  numbers  of 
these  run  in  lines  along  the  horizontal  axis  of  the  gut,  on  both  sides  of  and  close 


DEATH    FIFTY-OXE    DAYS   AFTER   A    MINOK    OPERATIOX.  547 

to  the  circular  vessels.  On  section  these  are  seen  to  contain  necrotic  material 
and  grayish-yellow  pus.  There  are  only  a  few  miliary  abscesses  in  the  wall  of 
the  large  gut.  An  occasional  small  abscess  can  be  made  out  in  the  fat  around 
the  colon.     The  rectum  is  normal. 

The  mucous  membrane  of  the  vagina  is  smooth  ;  in  its  upper  part  are  two 
folds  held  in  place  by  two  silkworm-gut  ligatures  which  run  through  the  cervix 
and  vagina.     There  is  no  evidence  of  inflammatory  reaction  about  them. 

The  uterus  is  7  centimeters  long,  4  centimeters  "wide  at  its  widest  part,  and 
3  centimeters  antero-posteriorly.  Its  cavity  from  fundus  to  external  os  meas- 
ures 6  centimeters.  The  average  thickness  of  the  uterine  walls  is  8  millimeters. 
The  mucous  membrane  is  smooth  and  looks  normal. 

The  ligaments  of  the  uterus  and  its  adnexa  are  very  much  relaxed  and 
lengthened.  The  right  uterine  tube  is  4  centimeters  (1^  inch)  long ;  the  sur- 
face is  smooth.  The  right  ovary  is  small,  atrophic,  and  contains  at  its  outer 
end  a  cyst  1  centimeter  in  diameter  filled  with  clear  straw-colored  fluid.  On 
section  the  ovary  is  very  fibrous  and  in  its  substance  contains  a  small  nodule 
about  the  size  of  a  pea,  which  is  filled  with  shreddy  grayish-white  material.  On 
the  outer  surface  of  the  ovary  are  very  numerous  minute  cysts  about'  the  size  of 
a  bird  shot.  They  contain  serous  fluid.  There  are  a  number  of  these  also  in 
the  broad  ligament  on  this  side.  The  miliary  purulent  foci  are  also  seen  in  the 
broad  ligament.  The  left  uterine  tube  is  5  centimeters  (4  inches)  long.  The 
left  ovary  is  small,  and  on  its  surface  and  along  the  surface  of  the  ovarian  liga- 
ments are  many  extremely  minute  cysts  containing  serous  fluid,  like  those  on 
the  other  side.  Around  the  ovarian  ligaments  and  near  the  uterus  are  four 
larger  cysts  with  gelatinous  contents  about  the  size  of  a  hazelnut.  The  pelvic 
peritoneum  is  smooth  and  shows  no  signs  of  inflammation.  The  bladder  is 
normal. 

In  the  perineum  are  marks  of  recent  stitch  holes,  and  in  the  perineal  tissue, 
beneath  the  operation  site  which  extensively  shows  a  healed  wound,  is  a  small 
cavity  filled  with  greenish-yellow  pus.  Pus  can  be  squeezed  from  several  points 
in  this  tissue. 

Microscopic  Examination. — Coverslips  from  purulent  foci  in  dif- 
ferent parts  show  very  many  cocci,  chiefly  in  pairs.  They  are  often  biscuit- 
shaped.  Frozen  sections  of  heart  muscles  generally  not  fatty.  In  the  white 
opaque  areas  the  muscle  fibers  are  necrotic,  and  there  are  many  small  round 
cells  accumulated  there.  The  lung  shows  many  dilated  alveoli.  The  alveolar 
epithelium  is  swollen.  Some  coal  pigment  in  perivascular  and  peribroncliial 
connective  tissue.  The  liver  cells  are  much  swollen  and  are  very  granular. 
The  central  veins  are  dilated,  as  are  also  the  cajullaries.  The  liver  cells  around 
the  central  veins  are  distinctly  pigmented,  while  the  cells  in  the  periphery  of 
the  lobules  are  fatty.  There  is  no  marked  increase  in  the  connective  tissue  of 
the  liver.  In  the  kidney  collections  of  leucocytes  are  numerous  in  the  cortex. 
There  are  several  collections  of  pus  cells  along  the  intortuhular  vessels  in  the 
pyramids.  The  epithelium  of  the  convoluted  tubules  is  much  swollen  and 
granular.  Many  cells  have  been  desquamated,  and  the  cells  left  are  loosened 
78 


548  0^"   THE    CONDUCT   OF    AUTOPSIES. 

from  one  another.  There  has  also  been  swelling  and  desquamation  in  the  col- 
lecting tubes.  There  is  some  fatty  hyaline  degeneration  in  the  secreting  tubules. 
The  glomerular  vessels  are  dilated.  In  a  few  places  there  is  fatty  degeneration 
of  the  glomerular  epithelium.  In  some  areas  there  is  thickening  of  the  capsule 
of  Bowman,  and  occasionally  a  completely  obliterated  Malpighian  body  can  be 
seen.  In  these  areas  the  connective  tissue  is  increased  about  the  blood  vessels 
and  between  the  tubules. 

The  Cultures. — The  cultures  on  Esmarch's  agar,  from  heart's  blood, 
abscess  in  myocardium,  Hver,  spleen,  and  kidney,  contain  colonies  of  staphy- 
lococcus pyogenes  aureus,  but  no  other  bacteria.  The  colonies  are 
yellow,  and  in  twenty-four  hours  the  color  slips  showed  typical  clusters.  The 
agar  Esmarch  was  too  crowded  to  allow  one  to  get  at  single  colonies.  Gelatin 
rolls  made  from  this  showed  only  one  variety  of  micro-organism,  which  proved 
to  be  the  same  staphylococcus,  which  is  slow  in  liquefying  gelatin.  At 
the  end  of  three  days  there  is  no  liquefaction.  At  the  end  of  seven  days  there 
is  liquefaction  in  the  neighborhood  of  the  individual  colonies,  and  fine  granular 
sediment  of  cocci  in  the  pendant  portion  of  liquefied  medium. 


INDEX  OF  CASES   FROM  THE  JOHNS   HOPKINS   HOSPITAL. 


pi-ec 


Adeno-carcinoma  of  uterus  with  cystic  degen- 
eration      

Adeno-rayoma  uteri  diffusum  benignura 

Angio-sarcoma  of  ovary     ... 

Anastomosis  between  loops  of  ileum 

Cesarean  section         .... 

Cesarean  section,  myoma  complicating 
nancy       

Cancer  of  ovary,  with  fibroid  uterus 

Carcinoma  of  cervix  .... 

Carcinoma  of  uterus,  with  myoma    . 

Cornual  myoma 

Cystectomy  during  pregnancy  . 

Cystic  myoma  with  twisted  pedicle  . 

Dermoid  of  ovary,  with  fibroid  uterus 

Emphysema  of  abdominal  wall 

Extensive  tear  of  rectum  at  pelvic  floor 

Exti'a-uterine  pregnancy  . 

Fecal  fistula 

Fecal  fistula 

Femoral  hernia  .        . 

Fibroid  ovary  during  pregnancy 

Fibroid  tumor  of  ovary     . 

Fibro-cystic  tumor    .... 

Fibroma  of  ovary       .... 

Fistula  opening  into  cecum 

Hematoma  of  ovary  .... 

Hemorrhage 

Hemorrhage       ..... 

Hydrosalpinx  and  ovarian  cyst  during 
nancy       

Hystero-salpingo-oophorectomy 

Heo-cecal  anastomosis 

Reus  due  to  Trendelenburg  position 

Interstitial  myoma     .... 

Late  shock 

Late  shock 

Lavage        

Multilocular  ovarian  cystoma   . 

Myoma  during  pregnancy 

Myouui  of  uterus        .... 


preg- 


J.  H.  A.,  San.  260,  December  13.  1895 

L.  W.,  Path.  No.  497,  October  31,  1894 

L.  R.,  2894,  July  7,  1894 

M.  L.  N.,  1824,  March  1,  1893 

E.  D.,  2412,  January  14,  1891 


R.  P.  S.,  8819,  December  16,  1893 

E.  M.,  Path.  Xo.  1009,  December  11,  1895 

S.  L.,  2248,  October  16,  1893  . 

L.  W..  1069.  November  23,  1891 

S.  L.,  2500,  January  15,  1894. 

M.  E.,  1188,  February  3,  1892 

A.  Y.,  4485,  July  2.  1896 

J.  Q.,  3250,  December  29,  1894 

N.  W.  W.,  377i,  September  12,  1895 

M.  P.,  5014,  February  13,  1897 

A.  L.,  191,  May  6,  1890  . 
J.  II.,  2547,  February  1,  1894 

B.  W.  M.,  3108.  October  16,  1894 
H.  S..  5111,  3Iarcli  20,  1897  . 
A.  R.,  2042,  June  21,  1893   . 
G.  Y.,  San.  211,  May  21,  1895 
J.  S.  S.,  San.  107,  May  12,  1894 
A.  S.  W.,  5061,  March  10,  1897 

E.  B.,  4146^  February  15,  1896 
M.  B.,  3346,  March  27,  1895  . 

C.  L.,  1926,  April  19,  1893  . 
M.  R.,  2752,  September  8,  1894 

n.  L.,  1249,  August  20,  1894. 
M.  11..  4183,  March  2.  1896  . 
M.  F.,  2237A,  October  7,  1893 
:\I.  C,  2193,  September  11,  1893 

F.  E.  S.,  4055,  January  6,  1896 
:\I.  D.,  3320,  February's,  1895 
M.  \\\.  3296,  January  30,  1895 
R.  1?..  4S2S.  Novemlx'r  23,  1896 

G.  II.  K..  4224.  March  21,  1896 
:M.  S..  1249,  .March  10,  1892  . 
J.  J..  77,  autopsy,  February  1.  1890 

549 


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409 
289 
343 
174 
495 
189 
66 
66 

408 

195 

513 

110 

360 

59 

59 

76 

183 

410 

539 


550 


INDEX    OF    CASES    FROM    THE    LITERATURE. 


Myoma  simulating  pregnancy  . 
Myomata,  eight,  removed  by  seven  incisions 
Ovariotomy         .... 
Ovariotomy         .... 
Papillary  eyst-adeno-sarcoma   . 
Papilloma  of  ovary    . 
Papilloma  of  ovary    . 
Papilloma  of  ovary    . 
Papilloma  of  ovary    . 
Parovarian  cyst .... 
Parovarian  cyst .... 
Parovarian  cyst  during  pregnancy 
Pelvic  abscess     .... 
Perineorrhaphy .... 

Peritonitis 

Pneumonia  following  operation 
Post-operative  septic  peritonitis 
Purulent  hemorrhagic  peritonitis 
Salpingo-oophorectoniy 
Septic  infection  . 
Septicemia. 
Septicemia. 
Sigmoido-proctostomy 
Sudden  death  from  embolus 
Suppurating  ovarian  cyst  . 
Suppurating  myoma  . 
Suspension  of  the  uterus   . 
Suspension  of  the  uterus    . 
Tear  of  rectum  . 
Tubercular  peritonitis 
Tubercular  peritonitis 
Uterus  sutured  to  rectum  . 


PAGE 

V.  W.,  3198,  November  28,  1894  .  .  .400 
M.  A.,  1576,  November  5,  1893  .  .  .360 
J.  S.,  3333,  February  25,  1895  .  .  .196 
S.  T.  W.,  examination,  San.,  February  2, 1897  526 
M.  G.,  3100,  October  13,  1894  .  .  .375 
A.  W.,  5069,  March  6,  1897  .  .  .  .174 
C.  K.,  2592,  February  17,  1894  .  .  .269 
J.  H.  E.,  San.  59,  August  16,  1893  .  .  268 
L.  K.  W.,  1189,  February  10,  1893  .  .  174 
Ii.  W.,  1171,  January  27,  1892  .  .  .282 
P.  T.,  604,  March  14,  1891  .  .  .  .282 
S.  M.,  2561,  January  4,  1894  ....  408 
A.  C,  4186,  March  4,  1896  .  .  .  .339 
M.  H.,  1805,  February  7, 1893  .  .  .544 
M.  E.  A.,  1763,  January  21,  1893  .  .  .542 
L.  Y.,  2677,  March  29,  1894  .  .  .  .107 
V.  W.,  3198,  November  8,  1894  ...  84 
E.  E.  H.,  6583,  January  23,  1893  ...  85 
E.  D.,  3391,  March  23,  1895  .  .  .  .196 
L.  F.,  2613,  March  1,  1894      ....      67 

A.  M.,  3110,  April  3,  1894  .  .  .  .103 
S.  W.,  3304,  November  38,  1894    .        .        .101 

B.  W.  M.,  1161,  October  80,  1894  .  .  .511 
M.  E.  H.,  2325,  September  25, 1893  (admission)  130 
E.  B.  L.,  4946,  January  20,  1897     .        .      298,  497 

A.  S.,  3216,  December  3,  1894  .  .  .383 
E.  B.,  3701,  April  6,  1894  .  .  .  .153 
J.  A.  H.,  San.  332,  June  26,  1892  .  .  .158 
J.  S.,  332,  September  2,  1890  ....      20 

B.  M.,  14,  October  18,  1889  ....  138 
K.  J.,  2597,  February  21,  1894  .  .  .148 
J.  S.,  357,  September  2,  1890  .         .        .         .505 


INDEX   OF   CASES   FEOM   THE   LITERATUKE. 


Appendicitis  during  pregnancy  .... 
Appendicitis  during  pregnancy     .... 

Cesarean  section 

Cesarean  section  and  symphyseotomy  on  different 

occasions  in  same  woman  .... 
Cesarean  section  in  a  case  of  osteo-sarcoma  of 

pelvis 

Cesarean  section  twice 

Dermoid  cyst  during  pregnancy  .... 
Dermoid  cyst  during  pregnancy  .... 
Dermoid  cyst  during  pregnancy    .... 

Dermoid  cyst  of  ovary 

Dermoid  cyst  of  ovary 

Extirpation  of  the  uterus 


P.  F.  MUNDE        .... 

L.  L.  McArthur 

E.  J.,  April  17,  1888,  II.  A.  Kelly. 


K.  G.,  May  30,  1888,  II.  A.  Kellv. 


.    413 

413,  414 

.    417 

.     416 


M.  S.,  May  10,  1889.  H.  A.  Kelly     .        .  416 

1835-1837,  (Mrs.  Reybold)  William  Gibson  421 

B.  C.  Hirst 408 

R.  MoRisoN 409 

C.  Staude  .        .  ....  408 

C.  Schroder 181 

P.  F.  Munde 277 

G.  Kimball 365 


IXDEX    OF    CASES    FROM   THE    LITERATURE. 


551 


Extra-uterine  pregnancy 

Extra-uterine  pregnancy 

Extra-uterine  pregnancy 

Extra-uterine  pregnancy 

Extra-uterine  and  intra-uterine  pregnancy 

Extra-uterine  and  intra-uterine  pregnancy 

Fibroid  of  ovary 

Hysterectomy  for  fibroid  tumor    , 

Hysterorrhaphy 

Intraligamentary  myoma  with  twin  pregnancy 
Inguinal  hernia  in  women 
Ovarian  carcinoma         .... 
Ovarian  cyst  with  pregnancy 
Ovariotomy  during  pregnancy 
Panhysterectomy  for  uterine  fibroid 
Papillary  cyst-adeno-sarcoma 
Papilloma  of  ovary        .... 
Papilloma  of  ovary        .... 
Pregnancy  in  rudimentary  horn  of  uterus 
Pyosalpinx  in  pregnancy 
Pregnancy  following  conservatism 
Pregnancy  following  conservatism 
Pregnancy  following  conservatism 
Pregnancy  following  conservatism 
Pregnancy  following  conservatism 
Removal  of  fibroid  tumor 
Suppurating  appendages  during  pregnancy 


H.  A.  Kelly 

H.  C.  CoE    . 

KoEBERLE  and  Lecluyse 

C.  Fexger  . 

H.  P.  C.  WiLSox 

A.  L.  Galabin    . 

a.  schachner    . 

Walter  Burxham 

M.  A.  W.,  April  25,  1885, 

W.  J.  Taylor 

W.  S.  Halsted 

A.  Hemple 
C.  Jacobs    . 
J.  M.  Baldy 
M.  A.  D.  JoxES 
Pfaxxexstiel 

LOMER 

K.  Thorxtox 

G.  W.  WiLKIXS 

Kaltexbach 

B.  F.  Baer 

A.  p.  Dudley 

B.  Mac^Moxagle 
W.  M.  Polk 

A.  SiPPLE     . 

W.  L.  Atlee 

H.  MiCHIE   . 


H.  A. 


Kelly 


PAGE 

445 
430 
433 
462 
442 
442 
289 
364 
149 
411 
481 
276 
409 
413 
365 
274 
266 
266 
465 
412 
190 
189 
190 
188,  191 
191 
364 
412 


INDEX 


Abdominal  dressing,  42. 

hysterectomy  for  carcinoma  and  sarcoma  of 
the  uterus,  305. 

incision,  12. 

operations  upon  the  myomatous  uterus,  354. 
Abscess,  pelvic,  forms  of,  209. 
Accessory  ostia,  432. 
Adeno-carcinoma  of  cervix,  310. 

of  body  of  uterus,  310. 

of  ovary,  275. 
Adeno-myoma  uteri  diffusum  benignum,  385. 
Adherent  Fallopian  tubes,  183. 

tubes  and  ovaries,  374. 
Adhesions,  methods  of  dealing  with,  17,  493. 

to  myomata,  497. 

to  ovarian  cysts.  497. 

to  pelvic  abscesses,  498. 

to  uterus,  496. 
Amputation  of  diseased  tubes,  186. 
Anastomoses : 

end  to  end,  507. 

end  to  side,  511. 

ileo-cecal,  513. 

lateral,  505. 
Anastomosis  buttons,  515. 
Anatomical  changes  due  to  operation,  521. 
Appendieal  adhesions,  21. 
Appendicitis,  499. 

with  pregnancy,  413. 
Artificial  anus,  516. 

menopause,  525. 
Atresia  of  one  tube  with  external  migration  of 
the  fertilized  ovum  from  the   opposite  side, 
430. 
Autopsy,  methods  of  conducting,  531. 

how  to  close  up  a  body,  530. 

IJacillus  coli  comnuinis.  83. 

lactis  aerogenes,  211. 
Bandage,  45. 

Bathing  after  operation,  45. 
Bimanual  compression  of  [tus  sac,  221. 
Bowels  after  o])oration,  51. 


Cesarean  section,  415. 
competitive  operations : 
craniotomy,  415. 
premature  labor,  416. 
symphyseotomy,  415. 
turning,  415. 
use  of  forceps,  416. 
conservative  Cesarean  operation,  416. 
in  agonia,  427. 
indications  for,  415. 
on  the  dead,  427. 
Porro-Cesarean  operation,  423. 
Cancer  of  the  uterus,  with  myoma  or  tuberculo- 
sis, 311. 
of  the  uterus,  associated  with  myomata,  380. 
Carcinoma  of  ovary,  275,  379. 
of  cervix,  with  pregnancy,  411. 
of  the  uterus,  305. 
Care  of  wound,  44. 

Castration  for  extreme  dysmenorrhea,  195. 
Catheterization  after  operation,  51. 

of  the  ureters,  323. 
Changes  in  vagina  due  to  operation,  524. 

in  uterus  due  to  operation,  524. 
Chemical  tost  to  determine  the  presence  of  pscu- 

domucin,  261. 
Charts : 

analysis  of  urine,  5. 

chart  showing  high  pulse  rate  with   recovery, 

72. 
chart  showing  relative  time  of  continuance  of 
fever  after  operation   for  tubercular   peri- 
tonitis, with  and  without  drainage.  146. 
composite  chart  of  cases  of  tubercular  peri- 
tonitis not  drained,  140. 
composite  charts  showing  the  avt>rage  range 
of  pulse  and  teinpcniture  for  ten  days  after 
operation,  54. 
composite  urinary  chart  of  one  hundred  cases, 

with  and  without  saline  enemata,  50. 
malarial  chart,  75. 
jineumonia  chart,  108. 
recovery  in   tubular  peritonitis   showing  the 


553 


554: 


INDEX. 


characteristic  defervescence  after  operation 
without  drainage,  147. 
stitch-hole  abscess  chart,  115. 
temperature  and  pulse   chart   (general  sepsis 

from  local  vaginal  infection),  102. 
temperature  and  pulse  chart  (septic  peritoni- 
tis, following  myomectomy),  86. 
typical  temperature  and   pulse  chart  (septi- 
cemia from  purulent  peritonitis),  103. 
Cleansing  the  abdomen,  10. 
Clear  space,  198,  241. 
Closure  of  the  incision,  40. 
Colostomy,  516. 

Complications   arising   after   abdominal   opera- 
tions, 56. 
Conservative  operations  on  the  tubes  and  ova- 
ries, 163. 
importance  of  conserved  structures,  165. 
limitations  of,  171. 
objections  to,  172. 
on  the  ovary,  173. 
on  the  uterine  tubes,  183. 
reasons  for,  164. 
Cornual  myoma,  361. 
Course  of  an  inflammatory  process,  213. 
Cultures,  548. 
Curettage,  352. 

Cystic  myoma  uteri  with  twisted  pedicle,  384. 
Cysto-myoma,  382. 
Cysts  of  the  corpus  luteum.  180. 

Dermoid  cyst,  379,  406. 

cysts  of  ovary,  181,  277. 
Diet  lists,  47. 
Diverticula  from  the  lumen  of   the   Fallopian 

tube,  431. 
Drainage : 
after  operation  for  tubercular  peritonitis,  147. 
cases  to  be  drained,  37. 
function  of  the  peritoneum  under  normal  and 

pathological  conditions,  30. 
how  to  put  in  and  take  out  a  drain,  37. 
mechanism  of  absorption  of  fluids  and  solid 

particles  in  the  peritoneal  cavity,  33. 
objections  to,  35. 
of  tubal  abscesses,  187. 
physiology  of,  29. 

prevention  and  removal  of  infection  without 
drainage,  36. 

Egg  albumen,  47. 

Elevation  of  tubes  and  ovaries  by  myomata,  389. 
Emphysema  of  abdominal  wall,  127. 
Emptying,  cleansing,  or  sterilization  of  inflamed 
tubes,  185. 
the  sac  by  massage,  221. 


Encysted  peritonitis,  377,  524. 

Endothelioma  of  the  cervix,  333. 

Enlargement  and  tenderness  of  scar,  523. 

Enterocele,  523. 

Enucleation  of  pyosalpinx  and  ovarian  abscess, 

231. 
Epithelioma  of  cervix,  308. 

Evacuation  by  vagina  aided  by  an   abdominal 
incision,  227. 

through  the  rectum,  227. 
Examination  of  the  patient,  2. 
Exposure  of  field  of  operation,  14. 
Exsection  of  diseased  or  strictured  tubes,  187. 
Extirpation  of  submucous  myomata  per  abdo- 
men, 364. 
Extra-uterine  pregnancy,  187,  428. 

causes  of,  438. 

complicated  cases  of,  463. 

criteria  of,  435. 

diagnosis  of,  ruptured  and  unruptured,  443. 

forms  of,  433. 

interstitial,  441,  463. 

intraligamentary    and    pseudo-intraligamen- 
tary,  455. 

mortality  of,  449. 

multiple  pregnancy,  441. 

operations  for,  early  and  late,  450. 

repeated,  443. 

treatment  of  advanced,  456. 

vaginal  incision  and  drainage,  453. 

Facial  expression,  53. 

Fehling's  solution,  5,  262. 

Femoral  hernia,  490. 

Fermentation  and  septic  fevers,  97. 

Fermentation  fever,  99. 

Fibrocystic  tumors,  343. 

Fibroid  tumor,  clinical  character  of,  339. 

tumors  of  the  ovary,  285,  379. 
Fistul*,  495. 

fecal,  121. 

urinary,  120. 
Fistula?  and  sinuses,  523. 
Fixing  agents.  537. 
Fleming's  solution,  538. 
Food,  47. 

Forceps  labor,  416. 
Formalin,  538. 

Function  of  the  peritoneum  under  normal  and 
pathological  conditions,  30. 

Galvanism,  354. 

General   principles  and  complications  common 

to  abdominal  operations,  1. 
Globular  myoma  filling  pelvis,  389. 
Gonococcus,  210. 


INDEX. 


555 


Graafian  cysts,  177. 
follicles,  177. 

Health  of  surgeon,  1. 
Heller's  nitric-acid  test,  5. 
Hematoma  of  the  ovary,  181, 379. 
Hemorrhage,  26. 

from  rayoniata,  352. 

secondary,  61. 
Hermann's  fluid,  538. 
Hernia,  the  radical  cure  of,  467. 

femoral,  490.  , 

inguinal,  481. 

in  the  linea  alba,  471. 

modes  of  origin,  467. 

operations  for  radical  cure  of.  467. 

umbilical,  476. 
Hoffman's  anodyne,  77. 
Hydatid  of  Morgagni,  283. 
Hydrops  tubje  profluens,  202. 
Hydrosalpinx,  374. 

follicularis,  203. 

simplex,  199. 
Hysterectomy : 

abdominal,  for  carcinoma  and  sarcoma  of  the 
uterus,  305. 

analysis  of  one  hundred  cases  of,  245. 

complications  of,  244. 

mortality  of,  245. 

with  extirpation  of  ovaries  and  tubes — ab- 
dominal hystero-salpingo-oophorectomy,  236. 
Hystero-myomectomy,  338,  355,  364. 

with  complications,  373. 

without  complications,  368. 
Hysteropexy,  149. 
Hysterorrhaphy,  149. 
Hystero-salpingo-oophorectomy,  236. 

Ileus,  109. 

Illumination  of  the  field,  17. 

Incision,  12. 

closure  of,  12. 

exploratoi'y,  12. 

in  fat  women,  12. 

length  of,  12. 
Incarcerated  pregnant  uterus.  406. 
Inflammatory   affections  as   a   cause  of   extra- 
uterine pregnancy.  432. 
Infusion.  70. 
Inguinal  hernia,  481. 
Injuries  to  bladder  and  ureters,  23. 
Insanity,  527. 

Internal  secretion  of  ovary,  165. 
Interstitial  myomata.  342. 

pregnancy,  441,  463. 
Intestinal  adhesions,  378,  523. 


Intestinal  anastomosis,  505. 
Intestinal  complications,  492. 
Intestinal  needles,  501. 
Intestinal  sutures,  501. 
Intestines : 

circular  suture  of.  with  the   use   of   inflated 
rubber  cylinders,  509. 

fibrous  coat  of,  501. 

suture  of,  500. 

tear  of  peritoneal  and   muscular    coats    of, 
503. 
Intraligamentary  cysts,  300. 
Irritability  of  bladder  and  decrease  in  urinary 

secretion,  49. 

Leaving  piece  of  an  organ  on  bowel.  497. 

Ligation  of  the  pedicle.  24. 

Liver,  adhesions  to,  378. 

Local  changes  due  to  operation,  524. 

Manual  reduction  of  retroflexion,  150. 
Mechanism  of  the  absorption  of  fluids  and  solid 

particles  in  the  peritoneal  cavity.  33. 
Menstruation,  524. 
Micrococcus  lanceolatus.  211. 
Moral     questions     involved     in     gynecological 

operations,  518. 
Morphia,  46. 
Miiller's  fluid,  538. 

Multilocular  ovarian  cyst  adenoma,  259. 
Multiple  pregnancy,  441. 
Myoma  below  posterior  pelvic  peritoneum,  392. 

below  vesical  peritoneum,  391. 

developed  antero-laterally,  395. 

developed  postero-latcrally,  396. 

developing  under  pelvic  peritoneum  in  several 
positions  at  once,  396. 

displacing  ureters  upward,  398. 

in  broad  ligament  proper,  393. 

in  upper  broad  ligament.  393. 

simulating  pregnancy,  400. 

wedged  in  pelvis,  390. 

with  ascites,  feeble  heart,  etc.,  401. 

with  pregnancy.  400,  409. 
Myoma  uteri  causing  extra-uterine  pregnancy, 

433. 
Myomata,  338. 

diagnosis  of.  348. 

kinds  and  sites  of.  341. 

operation  for,  354. 

palliative  treatment  of,  351. 

Nausea,  46,  75. 

Xophritis.  118. 

Xornial  salt  solution,  infusion  of,  70. 

Nutrient  enoniata.  61. 


556 


INDEX. 


Omental  adhesions,  18,  377. 
Opening  or  resection  of  closed  tubes,  185. 
Operation  for  abdominal  hysterectomy  for  can- 
cer, 321, 
Operations  during  pregnancy,  403. 
Osteomalacia,  167. 
Ovarian  abscess,  182. 

adhesions,  176. 
Ovarian  cystoma,  182,  879,  406. 
Ovarian  feeding,  168. 
Ovarian  hernia,  486. 
Ovarian  hydrocele,  379. 
Ovarian  tumors  in  general,  246-379. 

benign  and  malignant,  248. 

clinical  course  of,  253. 

diagnosis  of,  253. 

kinds  of,  246. 

pathology  of,  247. 

relative  frequency  of  kinds,  247. 

treatment  of,  292. 
Ovariotomy,  246. 

during  pregnancy,  407. 

Pain,  excessive,  78. 
Papillary  adeno-carcinoma,  273. 
Papillary  adenoma,  272. 
Papillary  cyst-adeno-sarcoma,  274. 
Papillary  cystic  Graafian  follicle,  272. 
Papillary  parovarian  cyst,  271. 
Papillary  tumors  of  the  ovary,  265. 
Parasitic  myoraata,  345. 
Parietal  adhesions,  377. 
Parovarian  cysts,  175,  248,  281,  406. 
Pedicle,  248. 

ligation  of,  298. 

rotation  of,  250. 
Pedunculate  myoraata,  357. 
Pelvic  abscess,  209. 

natural  terminations  of,  217. 
Pelvic  peritonitis,  433. 
Peritoneal  bands,  494. 

bands  and  adhesions  due  to  pelvic  peritonitis 
compressing  the  Fallopian  tube,  433. 
Peritonitis,  79. 

post-operative  septic,  82. 

traumatic  or  plastic,  80. 
Persistence  of  a   fetal  type  of  Fallopian  tube, 

481. 
Pessaries,  150. 
Phlebitis,  126. 
Phthisical  fades,  138,  142. 
Placenta  praevia  Cesariana,  418. 
Pleurisy,  106. 
Pneumonia,  107. 
Porro-Cesarean  operation,  423. 
Position  in  bed,  45. 


Post-mortem  examination,  531. 

Pregnancy,  cases  of,  after  conservative  opera- 
tions, 188. 
operations  during,  403. 

Pregnancy  and  tubercular  peritonitis,  137. 

Pregnancy  and  ovarian  tumors,  255. 

Pregnancy  complicating  carcinoma  of  the  cer- 
vix, 312. 

Pregnancy  in  a  rudimentary  horn  of  the  uterus, 
464. 

Premature  labor,  416. 

Preparation  of  patient  for  operation,  7. 
of  surgeon  and  assistants,  11. 

Preservation  of  tissues  for  microscopic  examina- 
tion, 537. 

Pressure  symptoms,  341. 

Prevention   and  removal   of  infection   without 
drainage,  36. 

Proteus  Zenkeri,  211. 

Protocol!,  J.  J.,  589. 

II,  M.  E.  A.,  542. 

III,  M.  H.,  544. 
Pseudomucin,  260. 

Pseudo-mucinous  papillary  adenoma,  272. 
Pulse,  53. 

peculiarities  of,  71. 
Purgatives,  81, 118. 
Pyemia,  105. 
Pyosalpinx,  212,  874. 

and  ovarian  abscess,  with  pregnancy,  412. 

Rectal  adhesions,  19. 
Rectum,  injury  of,  503. 
Regeneration  of  inflamed  tissues,  170. 
Relative  frequency  of  papillomata  and  carcino- 
mata.  266. 
importance  of  uterus,  ovaries,  and  tubes,  171. 
Release  of  adherent  tubes,  183. 
Remote  results  of  abdominal  operations,  518. 
Resection  of  relaxed  outlet,  150. 
Retroflexion,  149. 
Rotation  of  pedicle,  250. 
Rules  for  the  prevention  of  cancer,  817. 
Rupture  of  a  cyst,  252. 

Saline  enema,  48. 

purge,  52. 
Salpingitis,  catarrhal  and  purulent,  482,  433. 
Salpingo-oophorectomy,  simple,  193. 
Salpingo-Ofiphorectomy    for    hydrosalpinx    and 

adherent  tubes  and  ovaries,  199. 
Salt  solution,  70,  71. 
Sarcoma  of  the  cervix,  332. 

of  the  ovary,  290. 

of  the  uterus,  332,  334. 
Scarcity  of  literature  on  remote  results,  519. 


INDEX. 


557 


Scultetus  bandage,  43. 

Secondary  hemorrhage,  61. 

Sedatives  after  operation,  46. 

Septic  intoxication,  99. 

Septicemia,  101. 

Shock,  57. 

Special  diets,  48. 

Spermin,  166. 

Spindle-celled  sarcoma  of  the  cervix,  333. 

Staphylococus  aureus,  88. 

aureus  and  albus,  211. 
Stitch-hole  abscess,  114. 
Streptococcus  pyogenes,  83,  211. 
Strictures,  495. 
Submucous  myomata,  362. 
Subserous  or  subperitoneal  myomata,  342. 
Sudden  death,  128. 
Suppression  of  urine,  119. 
Suppuration,  114,  523. 

causes  of,  210. 
Suppurating  myoma,  382. 

ovarian  cyst,  298. 
Suspension  of  the  uterus,  149. 
Sutures,  removal  of,  53. 
Symphyseotomy,  415. 

Table  of  ectopic  viable  fetuses  delivered  by  celi- 
otomy, 458,  459. 
of  forms  of  extra-uterine  pregnancy,  434. 
showing  bacteriological  examination   of  pus 

from  ovaries  and  tubes,  212. 
showing  effect  of  castration  upon  the  composi- 
tion of  urine,  167. 
Tabulated   symptoms  of  traumatic   and   septic 

peritonitis,  90. 
Telangiectatic  myoma,  382. 
Temperature,  52. 
and  pulse  charts,  54.  72,  75,  86,  102,  103,  108, 

115. 
variations  in,  73. 


Thirst  after  operation,  48. 
Toilet  after  operation,  45. 
Torsion  of  the  Fallopian  tube,  433. 
Transplantation  of  the  ovary,  168. 
Treatment  of  ovarian  tumors,  292. 
Tubal  abortion,  439. 

mole,  440. 

polyps,  430. 
Tubercle  bacillus,  134,  142. 
Tubercular  peritonitis,  134. 
Tuberculosis  and  ovarian  tumoi'S,  255. 

of  the  endometrium,  381. 
Tubo-ovarian  cysts,  204. 
Turning,  415. 
Tympanites,  77. 

Umbilical  hernia,  476. 
Urinalysis,  3. 
Uterine  myoma,  409. 
Uterine  scrapings,  142. 

Vaginal  drainage  and  enucleation   for  pyosal- 

pinx,  ovarian  abscess,  tubo-ovarian  abscess, 

and  pelvic  abscess,  208. 
Vaginal  incision  and  drainage  for  extra-uterine 

pregnancy,  453. 
Vaginal  incision  and  drainage  for  pelvic  abscess, 

222. 
Ventral  hernia,  467. 
Ventrofixation,  149. 
Vermiform  appendix,  adhesions  to,  378. 

removal  of,  499. 
Vesical  adhesions.  23. 
Vetter  current  adapter,  17. 
Visitors,  proper  dress  and  conduct  of,  11. 
Vomiting,  75. 

Washing  out  stomach,  76. 
Wound,  dressing  of,  53. 
care  of,  44. 


THE   END. 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

WAYl  11941 

1 

C28  (747;  MlOO 

1 

/-  ^J'  3  ^ — - 
MAY!  11949   /^^^-r--^-^' 


